Beta-blocker efficacy across different cardiovascular indications: an umbrella review and meta-analytic assessment
Ziff, Oliver J Samra, Monica Howard, James P Bromage, Daniel I Ruschitzka, Frank Francis, Darrel P Kotecha, Dipak
Ziff, Oliver J
Samra, Monica
Howard, James P
Bromage, Daniel I
Ruschitzka, Frank
Francis, Darrel P
Kotecha, Dipak
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University of Birmingham; University College London; Imperial College London; Kings College London; University Hospital Zurich; Monash University; University Hospitals Birmingham NHS Foundation Trust
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Publication date
2020-05-05
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Abstract
Background: Beta-blockers are widely used for many cardiovascular conditions; however, their efficacy in contemporary clinical practice remains uncertain.
Methods: We performed a prospectively designed, umbrella review of meta-analyses of randomised controlled trials (RCTs) investigating the evidence of beta-blockers in the contemporary management of coronary artery disease (CAD), heart failure (HF), patients undergoing surgery or hypertension (registration: PROSPERO CRD42016038375). We searched MEDLINE, EMBASE and the Cochrane Library from inception until December 2018. Outcomes were analysed as beta-blockers versus control for all-cause mortality, myocardial infarction (MI), incident HF or stroke. Two independent investigators abstracted the data, assessed the quality of the evidence and rated the certainty of evidence.
Results: We identified 98 meta-analyses, including 284 unique RCTs and 1,617,523 patient-years of follow-up. In CAD, 12 meta-analyses (93 RCTs, 103,481 patients) showed that beta-blockers reduced mortality in analyses before routine reperfusion, but there was a lack of benefit in contemporary studies where ≥ 50% of patients received thrombolytics or intervention. Beta-blockers reduced incident MI at the expense of increased HF. In HF with reduced ejection fraction, 34 meta-analyses (66 RCTs, 35,383 patients) demonstrated a reduction in mortality and HF hospitalisation with beta-blockers in sinus rhythm, but not in atrial fibrillation. In patients undergoing surgery, 23 meta-analyses (89 RCTs, 19,211 patients) showed no effect of beta-blockers on mortality for cardiac surgery, but increased mortality in non-cardiac surgery. In non-cardiac surgery, beta-blockers reduced MI after surgery but increased the risk of stroke. In hypertension, 27 meta-analyses (36 RCTs, 260,549 patients) identified no benefit versus placebo, but beta-blockers were inferior to other agents for preventing mortality and stroke.
Conclusions: Beta-blockers substantially reduce mortality in HF patients in sinus rhythm, but for other conditions, clinicians need to weigh up both benefit and potential risk.
Citation
Ziff OJ, Samra M, Howard JP, Bromage DI, Ruschitzka F, Francis DP, Kotecha D. Beta-blocker efficacy across different cardiovascular indications: an umbrella review and meta-analytic assessment. BMC Med. 2020 May 5;18(1):103. doi: 10.1186/s12916-020-01564-3.
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Article