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Survival Among Patients Receiving Beta-Blockers After Acute Myocardial Infarction
Readers’ Comments
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disease and survival after cardiac catheterization. Am J Cardiol 2005;96:639 – 642. Cheng TO, Bashour T, Singh BK, Kelser GA Jr. Myocardial infarction in the absence of coronary arteriosclerosis: result of coronary spasm (?). Am J Cardiol 1972;30:680 – 682. Hurst JW. The Heart, Arteries and Veins. 7th ed. New York: McGraw-Hill, 1990:1893. Cheng TO. Pseudoinfarctions. Circulation 2001; 103:e69. Cheng TO. Pseudo-infarction pattern on electrocardiogram in pheochromocytoma. J Cardiol 2002;40:133. Lee GB, Wilson WJ, Amplatz K, Tuna N. Correlation of vectorcardiogram and electrocardiogram with coronary arteriogram. Circulation 1968;38:189 –200. Cheng TO: William Dock. Am J Cardiol 1999; 84:1215–1225. doi:10.1016/j.amjcard.2005.10.012
Survival Among Patients Receiving Beta-Blockers After Acute Myocardial Infarction Administration of -blockers has been a standard therapy after acute myocardial infarction, because it has been shown to reduce infarct size1 and mortality2,3 by decreasing the myocardial oxygen demand4 and modifying arrhythmic risk.2,5 However, the recent report by Lanfear et al6 seemed to challenge the validity of this practice. They found that, depending on the -adrenergic receptor genotypes of the patients, -blocker therapy may offer little benefit or even potential harm to a special patient subgroup.6 Survival among patients receiving -blocker therapy after acute myocardial infarction may not be increased or may even be decreased, according to a recently published study from China.7 The study, ClOpidogrel & Metoprolol in Myocardial Infarction Trial (COMMIT), the largest clinical trial ever undertaken in China on 45,852 patients and the second largest trial of acute myocardial infarction treatment in the world, indicated that metoprolol in acute myocardial infarction did not significantly reduce mortality in the hospital. Instead, it increased the risk of cardiogenic shock by 11 per 1,000 patients (p ⬍0.00001) chiefly on days 0 to 1.7 Another disquieting finding was the recent report from Sweden that a metaanalysis of 13 randomized controlled
trials involving nearly 106,000 patients found that the relative risk of stroke was 16% higher for -blockers (95% confidence interval 4% to 30%) than for other drugs.8 Furthermore, the same Swedish investigators found no convincing evidence that -blockers are any better than others at preventing myocardial infarction.8 These 3 recent studies once again prove that the modern practice of medicine has to be evidence-based.
Tsung O. Cheng, MD Department of Medicine George Washington University Medical Center Washington, DC 7 November 2005
1. Herlitz J, Waldenstrom J, Hjalmarson A. Infarct size limitation after early intervention with metoprolol in the MIAMI Trial. Cardiology 1988; 75:117–122. 2. -Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction. I: mortality results. JAMA 1982;247:1707–1714. 3. First International Study of Infarct Survival Collaborative Group. Randomized trial of intravenous atenolol among 16027 cases of suspected acute myocardial infarction: ISIS-1. Lancet 1986;2:57– 66. 4. Ohte N, Kurokawa K, Lida A, Narita H, Akita S, Yajima K, Miyabe H, Hayano J, Kimura G. Myocardial oxidative metabolism in remote normal regions in the left ventricles with remodeling after myocardial infarction: effect of beta-adrenoreceptor blockers. J Nucl Med 2002;43:780 –785. 5. Evrengul H, Dursunoglu D, Kayikcioglu M, Can L, Tanriverdi H, Kaftan A, Kilic M. Effects of a beta-blocker on ventricular late potentials in patients with acute anterior myocardial infarction receiving successful thrombolytic therapy. Jpn Heart J 2004;45: 11–21. 6. Lanfear DE, Jones PG, Marsh S, Cresci S, McLeod HL, Spertus JA. 2-Adrenergic receptor genotype and survival among patients receiving -blocker therapy after an acute coronary syndrome. JAMA 2005;294:1526 – 1533. 7. COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) Collaborative Group. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomized placebo-controlled trial. Lancet 2005;366:1607–1621. 8. Lindholm LH, Carlberg B, Samuelson O. Should  blockers remain first choice in the
1125 treatment of primary hypertension? A metaanalysis. Lancet 2005;366:1545–1553. doi:10.1016/j.amjcard.2005.11.003
Eisenhower’s Billion-Dollar Heart Attack In a recent publication, entitled “Eisenhower’s Billion-Dollar Heart Attack—50 Years Later,”1 the authors reminisced about President Eisenhower’s acute myocardial infarction in 1955. I can support everything said in the article, because Dr. Paul Dudley White, Eisenhower’s cardiologist, was my mentor and told me every detail about Eisenhower’s acute anterior myocardial infarction in 1955. I had the special honor of delivering the Second Paul Dudley White Lecture of the American College of Cardiology in 1973; the title of my Paul D. White Lecture was “Cardiology in the People’s Republic of China.”2 Dr. White often said to me that if Americans ate a Chinese diet, there would not be so many people with coronary artery disease in the United States. Of course, things have changed a great deal since then; coronary artery disease has climbed from the fifth most common form of heart disease in 1948 –1957 to the most common form of heart disease in 1980 –1989, where it has remained until today,3 the result of China’s modernization.4 It was not clear from the article as to what the investigators1 meant by the figure of a billion dollars in the title of their article. If they were referring to the Dow Jones’ decline of 14 billion on the day of Eisenhower’s heart attack, it would have been a 14-billion-dollar heart attack. If they implied that the treatment of Eisenhower’s heart attack costed 1 billion dollars in 1955, they ought to have given a breakdown of the cost. It was also unclear whether the billion dollars referred to Eisenhower’s first heart attack or the total of his 7 heart attacks. Finally, it would be of interest to know, if Eisenhower’s heart attack did cost 1 billion dollars in 1955, how much it would cost in 2005.
2.
3. 4. 5.
6.
7.
disease and survival after cardiac catheterization. Am J Cardiol 2005;96:639 – 642. Cheng TO, Bashour T, Singh BK, Kelser GA Jr. Myocardial infarction in the absence of coronary arteriosclerosis: result of coronary spasm (?). Am J Cardiol 1972;30:680 – 682. Hurst JW. The Heart, Arteries and Veins. 7th ed. New York: McGraw-Hill, 1990:1893. Cheng TO. Pseudoinfarctions. Circulation 2001; 103:e69. Cheng TO. Pseudo-infarction pattern on electrocardiogram in pheochromocytoma. J Cardiol 2002;40:133. Lee GB, Wilson WJ, Amplatz K, Tuna N. Correlation of vectorcardiogram and electrocardiogram with coronary arteriogram. Circulation 1968;38:189 –200. Cheng TO: William Dock. Am J Cardiol 1999; 84:1215–1225. doi:10.1016/j.amjcard.2005.10.012
Survival Among Patients Receiving Beta-Blockers After Acute Myocardial Infarction Administration of -blockers has been a standard therapy after acute myocardial infarction, because it has been shown to reduce infarct size1 and mortality2,3 by decreasing the myocardial oxygen demand4 and modifying arrhythmic risk.2,5 However, the recent report by Lanfear et al6 seemed to challenge the validity of this practice. They found that, depending on the -adrenergic receptor genotypes of the patients, -blocker therapy may offer little benefit or even potential harm to a special patient subgroup.6 Survival among patients receiving -blocker therapy after acute myocardial infarction may not be increased or may even be decreased, according to a recently published study from China.7 The study, ClOpidogrel & Metoprolol in Myocardial Infarction Trial (COMMIT), the largest clinical trial ever undertaken in China on 45,852 patients and the second largest trial of acute myocardial infarction treatment in the world, indicated that metoprolol in acute myocardial infarction did not significantly reduce mortality in the hospital. Instead, it increased the risk of cardiogenic shock by 11 per 1,000 patients (p ⬍0.00001) chiefly on days 0 to 1.7 Another disquieting finding was the recent report from Sweden that a metaanalysis of 13 randomized controlled
trials involving nearly 106,000 patients found that the relative risk of stroke was 16% higher for -blockers (95% confidence interval 4% to 30%) than for other drugs.8 Furthermore, the same Swedish investigators found no convincing evidence that -blockers are any better than others at preventing myocardial infarction.8 These 3 recent studies once again prove that the modern practice of medicine has to be evidence-based.
Tsung O. Cheng, MD Department of Medicine George Washington University Medical Center Washington, DC 7 November 2005
1. Herlitz J, Waldenstrom J, Hjalmarson A. Infarct size limitation after early intervention with metoprolol in the MIAMI Trial. Cardiology 1988; 75:117–122. 2. -Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction. I: mortality results. JAMA 1982;247:1707–1714. 3. First International Study of Infarct Survival Collaborative Group. Randomized trial of intravenous atenolol among 16027 cases of suspected acute myocardial infarction: ISIS-1. Lancet 1986;2:57– 66. 4. Ohte N, Kurokawa K, Lida A, Narita H, Akita S, Yajima K, Miyabe H, Hayano J, Kimura G. Myocardial oxidative metabolism in remote normal regions in the left ventricles with remodeling after myocardial infarction: effect of beta-adrenoreceptor blockers. J Nucl Med 2002;43:780 –785. 5. Evrengul H, Dursunoglu D, Kayikcioglu M, Can L, Tanriverdi H, Kaftan A, Kilic M. Effects of a beta-blocker on ventricular late potentials in patients with acute anterior myocardial infarction receiving successful thrombolytic therapy. Jpn Heart J 2004;45: 11–21. 6. Lanfear DE, Jones PG, Marsh S, Cresci S, McLeod HL, Spertus JA. 2-Adrenergic receptor genotype and survival among patients receiving -blocker therapy after an acute coronary syndrome. JAMA 2005;294:1526 – 1533. 7. COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) Collaborative Group. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomized placebo-controlled trial. Lancet 2005;366:1607–1621. 8. Lindholm LH, Carlberg B, Samuelson O. Should  blockers remain first choice in the
1125 treatment of primary hypertension? A metaanalysis. Lancet 2005;366:1545–1553. doi:10.1016/j.amjcard.2005.11.003
Eisenhower’s Billion-Dollar Heart Attack In a recent publication, entitled “Eisenhower’s Billion-Dollar Heart Attack—50 Years Later,”1 the authors reminisced about President Eisenhower’s acute myocardial infarction in 1955. I can support everything said in the article, because Dr. Paul Dudley White, Eisenhower’s cardiologist, was my mentor and told me every detail about Eisenhower’s acute anterior myocardial infarction in 1955. I had the special honor of delivering the Second Paul Dudley White Lecture of the American College of Cardiology in 1973; the title of my Paul D. White Lecture was “Cardiology in the People’s Republic of China.”2 Dr. White often said to me that if Americans ate a Chinese diet, there would not be so many people with coronary artery disease in the United States. Of course, things have changed a great deal since then; coronary artery disease has climbed from the fifth most common form of heart disease in 1948 –1957 to the most common form of heart disease in 1980 –1989, where it has remained until today,3 the result of China’s modernization.4 It was not clear from the article as to what the investigators1 meant by the figure of a billion dollars in the title of their article. If they were referring to the Dow Jones’ decline of 14 billion on the day of Eisenhower’s heart attack, it would have been a 14-billion-dollar heart attack. If they implied that the treatment of Eisenhower’s heart attack costed 1 billion dollars in 1955, they ought to have given a breakdown of the cost. It was also unclear whether the billion dollars referred to Eisenhower’s first heart attack or the total of his 7 heart attacks. Finally, it would be of interest to know, if Eisenhower’s heart attack did cost 1 billion dollars in 1955, how much it would cost in 2005.