COMMIT CCS-2研究课件.pptVIP

Perspective onCOMMIT/CCS-2 Trial of Metoprolol in STEMI First impression Wow !? I had predicted dramatic benefit with multiple 0’s in the P value Older B-blocker trials (up to 1986) 27,000 patients from 28 trials Meta-analysis: B-blocker (3.7%) Control (4.3%) 16% relative risk reduction 95% CI: 1-30% P=0.02 On re-looking: Lower risk patients studied Wide confidence intervals on mortality benefit Evolution of use of B-Blockers in AMI Benefits seen in meta-analysis of RCTs: reduced mortality, re-MI, VF, rec. ischemia Initially contraindicated if CHF Then, trials in outpatients with LV dysfunction, (with slow up-titration of dose over 3-6 mos) B-blockers shown to reduce mortality The overlap: in AMI, CHF no longer seen as a contraindication to use of B blockers Looking at the data in COMMIT/CCS-2 Benefit Reduction in re-MI Reduction in VF Risk Increased development of cardiogenic shock Biologically plausible – a negative inotropic agent Increased risk of shock in first 24-48 hours Subgroup analysis: Shock developed in Patients with Killip III, tachycardia, or hypotension Class I: Oral ?-blocker therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI. (Level of evidence: A) Class IIa: It is reasonable to administer iv ?-blocker promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present. (Level of evidence: B) ……the use of iv ?-blockade in the acute phase of infarction in many countries is extremely low. There is a good case for the greater use of an iv ?-blocker when there is tachycardia (in the absence of heart failure), relative hypertension, or pain unresponsive to opioids. It may be prudent to test the patient’s response to this form of therapy by first using a short-acting preparation. In most patients, however, oral ?-blockade will suffice. Conclusions: B-Blockade in Acute MI