Inpatient Insights
Should ß-blockers be interrupted or continued after myocardial infarction?
ß-blocker therapy is a standard of care for patients after myocardial infarction, with a prescription rate that has reached over 90% in most Western countries. However, early coronary reperfusion therapy has led to a sharp decrease in the risks of heart failure and death after myocardial infarction and has led to questions about the add-on benefits of lifelong b-blocker treatment in patients with a preserved left ventricular ejection fraction and no other primary indication for b-blocker therapy.
Members of the ACTION Group conducted a multicenter, open label, randomized, noninferiority trial at 49 sites in France to evaluate b-blocker continuation or interruption among patients with a history of myocardial infarction who had a left ventricular ejection fraction of at least 40%. They hypothesized that b-blocker interruption would be clinically safe and that the patients’ quality of life would improve.
The primary end point of the study, which was published on August 30, 2024, in NEJM, was a composite of death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for cardiovascular reasons at the longest follow-up (minimum 1 year), according to an analysis of noninferiority (defined as a between-group difference of <3 percentage points for the upper boundary of the two-sided 95% CI). The main secondary end point was the change in quality of life as measured by the European Quality of Life–5 Dimensions questionnaire. A primary outcome event occurred in 23.8% of patients in the interruption group and in 21.1% of patients in the continuation group. b-blocker interruption did not seem to improve the patients’ quality of life.
The authors concluded that interruption of long-term b-blocker treatment in patients with a history of myocardial infarction was noninferior to a strategy of b-blocker continuation with respect to a composite outcome of death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for cardiovascular reasons, nor did it seem to improve the patients’ quality of life. ■
Is there a dose-dependent association between empiric dexamethasone and outcome in viral meningitis?
Treatment with dexamethasone along with antibiotics reduces mortality and sequelae in adults with pneumococcal meningitis and hearing loss in those with Haemophilus influenzae type b meningitis. European and U.S. guidelines for managing bacterial meningitis in adults recommend initiating dexamethasone with the first dose of antibiotics and as soon as possible once meningitis is suspected, resulting in some patients with mimicking clinical features, such as those with viral meningitis, being treated with dexamethasone until bacterial meningitis has been excluded. However, the impact of this use of dexamethasone in patients with viral meningitis remains unclear.
Researchers from multiple hospitals in Denmark conducted an observational cohort study of adults hospitalized for viral meningitis to investigate whether there is a dose-dependent association between empiric dexamethasone and outcome in viral meningitis.
The study, published in Clinical Microbiology and Infection on August 23, 2024, involved 1,025 patients, of whom 64% did not receive dexamethasone, 11% received 1 or 2 doses, 13% received 3 or 4 doses, and 12% received 5 or more doses. Dose-dependent associations between dexamethasone (1 dose = 10 mg) and an unfavorable outcome (Glasgow Outcome Scale score 1–4) at 30 days after discharge were assessed using weighted logistic regression.
The researchers concluded that although treatment with dexamethasone for suspected bacterial meningitis was common in patients with a later diagnosis of viral meningitis, the duration was short in most cases and there was no dose-dependent association between dexamethasone and an unfavorable outcome in patients with viral meningitis. In enteroviral meningitis, 5 or more doses were associated with an increased risk of an unfavorable outcome. However, sensitivity analysis indicated that the association was affected by unmeasured or residual confounding by severity. ■
Are antivirals effective for treatment of severe influenza in hospitalized patients?
Influenza typically causes mild to moderate upper respiratory symptoms that resolve within a week, but young children (<5 years), older adults (≥65 years), pregnant women, and people with chronic medical conditions can develop severe illness from influenza and require hospitalization. However, the optimal antiviral drug for treatment of severe influenza remains unclear.
A group of researchers from China, Canada, Norway, and the United States performed a systematic review and network meta-analysis to evaluate antivirals for treatment of patients with severe influenza. For the study, published in the Lancet on August 24, 2024, the authors systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Global Health, Epistemonikos, and ClinicalTrials.gov for randomized controlled trials that enrolled hospitalized patients with suspected or laboratory-confirmed influenza and compared direct-acting influenza antivirals against placebo, standard care, or another antiviral.
Of the almost 12,000 records identified by the search, eight trials with 1,424 participants were included in this systematic review and six trials were included in the network meta-analysis. The results of the analysis indicated that the effects of oseltamivir, peramivir, or zanamivir on mortality compared with placebo or standard care without placebo for seasonal and zoonotic influenza were of very low certainty. Due to the small number of eligible trials, the researchers could not test for publication bias.
The authors concluded that in hospitalized patients with severe influenza, oseltamivir and peramivir might reduce duration of hospitalization compared with standard care or placebo, although the certainty of evidence is low. They noted that their findings primarily highlight the uncertainty regarding the effects of antivirals for treatment of patients with severe influenza but do provide some justification for their use. They suggested that more clinical trials are needed to inform the benefit, safety, and effects on antiviral resistance in patients with severe influenza. ■
Rethinking therapy in stable patients with coronary stents undergoing noncardiac surgery
Percutaneous coronary intervention with drug-eluting stents has become the most common strategy for myocardial revascularization in patients with symptomatic ischemic heart disease, with current guidelines recommending postponing elective noncardiac surgery for at least 6 to12 months after stent placement, continuing aspirin perioperatively to prevent stent thrombosis, and withholding P2Y12 inhibitors for 5 to 7 days before the procedure.
However, according to a recent study published on August 31, 2024, in the Journal of the American College of Cardiology, some observational studies found no association between the temporary discontinuation of antiplatelet therapy and perioperative adverse cardiac events, challenging these guideline recommendations.
Researchers in Korea, the ASSURE-DES investigators, conducted a trial to compare a strategy of continuing aspirin monotherapy versus holding all antiplatelet therapy for 5 days before noncardiac surgery in patients who are at least 1 year post cardiac surgery. Antiplatelet therapy was recommended to be resumed no later than 48 hours after surgery, unless contraindicated, and the primary outcome was a composite of death from any cause, myocardial infarction, stent thrombosis, or stroke between 5 days before and 30 days after noncardiac surgery.
Among 462 patients in the aspirin monotherapy group and 464 patients in the no antiplatelet therapy group, the primary outcome occurred in three patients (0.6%) in the aspirin monotherapy group and four patients (0.9%) in the no antiplatelet group. There was no stent thrombosis in either group, and the incidence of major bleeding did not differ significantly between groups. Minor bleeding was significantly more frequent in the aspirin group (14.9% vs. 10.1%).
The authors noted that given the lower-than-expected event rates as well as limitations in the methodology, these findings should be interpreted with caution and that further research with a large-scale study is needed to confirm these results, especially in higher-risk patients and surgeries. ■