Evaluation of metoprolol standard dosing pathway in Chinese patients with acute coronary syndrome: a prospective multicenter single-arm interventional study

Xiao-Yun YIN; Yun-Mei ZHANG; Ai-Dong SHEN; Jing-Ping WANG; Zhe-Xun LIAN; Yi-Bing SHAO; Wen-Qi ZHANG; Shu-Ying ZHANG; Yang ZHENG; Kang CHENG; Biao XU; Cheng-Xing SHEN; Rong-Chong HUANG; Jin-Cheng GUO; Guo-Sheng FU; Dong-Kai SHAN; Dan-Dan LI; Yun-Dai CHEN

doi:10.26599/1671-5411.2023.04.001

Volume 20 Issue 4

Apr. 2023

Turn off MathJax

Article Contents

Article Navigation > Journal of Geriatric Cardiology > 2023 > 20(4): 256-267

Please cite this article as: YIN XY, ZHANG YM, SHEN AD, WANG JP, LIAN ZX, SHAO YB, ZHANG WQ, ZHANG SY, ZHENG Y, CHENG K, XU B, SHEN CX, HUANG RC, GUO JC, FU GS, SHAN DK, LI DD, CHEN YD. Evaluation of metoprolol standard dosing pathway in Chinese patients with acute coronary syndrome: a prospective multicenter single-arm interventional study. J Geriatr Cardiol 2023; 20(4): 256−267. DOI: 10.26599/1671-5411.2023.04.001

Citation:

Please cite this article as: YIN XY, ZHANG YM, SHEN AD, WANG JP, LIAN ZX, SHAO YB, ZHANG WQ, ZHANG SY, ZHENG Y, CHENG K, XU B, SHEN CX, HUANG RC, GUO JC, FU GS, SHAN DK, LI DD, CHEN YD. Evaluation of metoprolol standard dosing pathway in Chinese patients with acute coronary syndrome: a prospective multicenter single-arm interventional study. J Geriatr Cardiol 2023; 20(4): 256−267. DOI: 10.26599/1671-5411.2023.04.001

Citation:

PDF( 819 KB)

Evaluation of metoprolol standard dosing pathway in Chinese patients with acute coronary syndrome: a prospective multicenter single-arm interventional study

doi: 10.26599/1671-5411.2023.04.001

1.
Senior Department of Cardiology, the Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
2.
Medical School of Chinese PLA, Beijing, China
3.
Department of Cardiology, Yunnan First People’s Hospital, Kunming, China
4.
Department of Heart Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
5.
Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, China
6.
Department of Cardiology, the Affiliated Hospital of Qingdao University, Qingdao, China
7.
Department of Cardiology, Qingdao Municipal Hospital, Qingdao, China
8.
Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
9.
Department of Cardiology, the Affiliated Zhongshan Hospital of Dalian University, Zhongshan, China
10.
Cardiovascular Center, the First Hospital of Jilin University, Changchun, China
11.
Department of Cardiology, the Affiliated Hospital of Northwest University & Xi’an No.3 Hospital, Xi’an, China
12.
Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
13.
Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
14.
Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
15.
Department of Cardiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
16.
Department of Cardiology, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China

More Information

Corresponding author: cardio_lidandan@163.com (LI DD); cyundai@vip.163.com (CHEN YD)
Publish Date: 2023-04-28

Abstract

Abstract

OBJECTIVE To evaluate the feasibility and tolerability of metoprolol standard dosing pathway (MSDP) in Chinese patients with acute coronary syndrome (ACS). METHODS In this multicenter, prospective, open label, single-arm and interventional study that was conducted from February 2018 to April 2019 in fifteen Chinese hospitals. A total of 998 hospitalized patients aged ≥ 18 years and diagnosed with ACS were included. The MSDP was applied to all eligible ACS patients based on the standard treatment recommended by international guidelines. The primary endpoint was the percentage of patients achieving the target dose at discharge (V2). The secondary endpoints included the heart rate and blood pressure at V2 and four weeks after discharge (V4), and percentage of patients experiencing bradycardia (heart rate < 50 beats/min), hypotension (blood pressure < 90/60 mmHg) and transient cardiac dysfunction at V2 and V4. RESULTS Of the 998 patients, 29.46% of patients achieved the target dose (≥ 95 mg/d) at V2. The total population was divided into two groups: target group (patients achieving the target dose at V2) and non-target group (patients not achieving the target dose at V2). There was significant difference in the reduction of heart rate from baseline to discharge in the two groups (-4.97 ± 11.90 beats/min vs. -2.70 ± 9.47 beats/min, P = 0.034). There was no significant difference in the proportion of bradycardia that occurred in the two groups at V2 (0 vs. 0, P = 1.000) and V4 (0.81% vs. 0.33%, P = 0.715). There was no significant difference in the proportion of hypotension between the two groups at V2 (0.004% vs. 0.004%, P = 1.000) and V4 (0 vs. 0.005%, P = 0.560). No transient cardiac dysfunction occurred in two groups during the study. A total of five adverse events (1.70%) and one serious adverse event (0.34%) were related to the pathway in target group. CONCLUSIONS In Chinese ACS patients, the feasibility and tolerability of the MSDP have been proved to be acceptable.

FullText(HTML)

References(48)

References

[1]	Bhatt DL, Lopes RD, Harrington RA. Diagnosis and treatment of acute coronary syndromes: a review. JAMA 2022; 327: 662−675. doi: 10.1001/jama.2022.0358
[2]	Gillman MW, Kannel WB, Belanger A, et al. Influence of heart rate on mortality among persons with hypertension: the Framingham Study. Am Heart J 1993; 125: 1148−1154. doi: 10.1016/0002-8703(93)90128-V
[3]	Ho JE, Larson MG, Ghorbani A, et al. Long-term cardiovascular risks associated with an elevated heart rate: the Framingham Heart Study. J Am Heart Assoc 2014; 3: e000668. doi: 10.1161/JAHA.113.000668
[4]	Woodward M, Webster R, Murakami Y, et al. The association between resting heart rate, cardiovascular disease and mortality: evidence from 112, 680 men and women in 12 cohorts. Eur J Prev Cardiol 2014; 21: 719−726. doi: 10.1177/2047487312452501
[5]	Fox K, Ford I, Steg PG, et al. Heart rate as a prognostic risk factor in patients with coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a subgroup analysis of a randomised controlled trial. Lancet 2008; 372: 817−821. doi: 10.1016/S0140-6736(08)61171-X
[6]	Ferrari R, Fox K. Heart rate reduction in coronary artery disease and heart failure. Nat Rev Cardiol 2016; 13: 493−501. doi: 10.1038/nrcardio.2016.84
[7]	Jain SKA, Larsen TR, Wiemann C, et al. Degree of beta-blockade and outcomes in patients with acute coronary syndrome. J Cardiovasc Dis Diagn 2014; 2: 1000150. doi: 10.4172/2329-9517.1000150
[8]	Consensus group of Chinese experts on appropriate use of beta-adrenergic receptor blocker in coronary heart disease. [Chinese expert consensus document on appropriate use of beta-adrenergic receptor blocker in patients with coronary heart disease]. Chinese Circulation Journal 2020; 35: 108−123. [In Chinese]. doi: 10.3969/j.issn.1000-3614.2020.02.002
[9]	Herman M, Donovan J, Tran M, et al. Use of beta-blockers and effects on heart rate and blood pressure post-acute coronary syndromes: are we on target? Am Heart J 2009; 158: 378−385. doi: 10.1016/j.ahj.2009.06.023
[10]	Irani F, Herial N, Colyer WR Jr. Impact of an acute coronary syndrome pathway in achieving target heart rate and utilization of evidence-based doses of beta-blockers. Am J Ther 2012; 19: 397−402. doi: 10.1097/MJT.0b013e3182068d91
[11]	Yusuf S, Peto R, Lewis J, et al. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis 1985; 27: 335−371. doi: 10.1016/S0033-0620(85)80003-7
[12]	de Matos Soeiro A, de Barros E Silva PG, Roque EA, et al. Mortality reduction with use of oral beta-blockers in patients with acute coronary syndrome. Clinics (Sao Paulo) 2016; 71: 635−638. doi: 10.6061/clinics/2016(11)03
[13]	O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61: e78−e140. doi: 10.1016/j.jacc.2012.11.019
[14]	Collet JP, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42: 1289−1367. doi: 10.1093/eurheartj/ehaa575
[15]	Li D, Dong W, Liu Y, et al. Impact of metoprolol standard dosing pathway in Chinese patients with acute coronary syndrome: protocol for a multicentre prospective study. BMJ Open 2019; 9: e031972. doi: 10.1136/bmjopen-2019-031972
[16]	Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130: 2354−2394. doi: 10.1161/CIR.0000000000000133
[17]	Alhalabi L, Singleton MJ, Oseni AO, et al. Relation of higher resting heart rate to risk of cardiovascular versus noncardiovascular death. Am J Cardiol 2017; 119: 1003−1007. doi: 10.1016/j.amjcard.2016.11.059
[18]	Zhang D, Shen X, Qi X. Resting heart rate and all-cause and cardiovascular mortality in the general population: a meta-analysis. CMAJ 2016; 188: E53−E63. doi: 10.1503/cmaj.150535
[19]	Aune D, Sen A, ó’Hartaigh B, et al. Resting heart rate and the risk of cardiovascular disease, total cancer, and all-cause mortality: a systematic review and dose-response meta-analysis of prospective studies. Nutr Metab Cardiovasc Dis 2017; 27: 504−517. doi: 10.1016/j.numecd.2017.04.004
[20]	Wang EY, Dixson J, Schiller NB, et al. Causes and predictors of death in patients with coronary heart disease (from the Heart and Soul Study). Am J Cardiol 2017; 119: 27−34. doi: 10.1016/j.amjcard.2016.09.006
[21]	Xu T, Zhan Y, Xiong J, et al. The relationship between heart rate and mortality of patients with acute coronary syndromes in the coronary intervention era: meta-analysis. Medicine (Baltimore) 2016; 95: e5371. doi: 10.1097/MD.0000000000005371
[22]	Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000; 101: 2557−2567. doi: 10.1161/01.cir.101.22.2557
[23]	Honda T, Kanazawa H, Koga H, et al. Heart rate on admission is an independent risk factor for poor cardiac function and in-hospital death after acute myocardial infarction. J Cardiol 2010; 56: 197−203. doi: 10.1016/j.jjcc.2010.05.006
[24]	Noman A, Balasubramaniam K, Das R, et al. Admission heart rate predicts mortality following primary percutaneous coronary intervention for ST-elevation myocardial infarction: an observational study. Cardiovasc Ther 2013; 31: 363−369. doi: 10.1111/1755-5922.12031
[25]	Kjekshus JK. Importance of heart rate in determining beta-blocker efficacy in acute and long-term acute myocardial infarction intervention trials. Am J Cardiol 1986; 57: 43F−49F. doi: 10.1016/0002-9149(86)90888-X
[26]	Rengo G, Lymperopoulos A, Zincarelli C, et al. Blockade of β-adrenoceptors restores the GRK2-mediated adrenal α₂adrenoceptor-catecholamine production axis in heart failure. Br J Pharmacol 2012; 166: 2430−2440. doi: 10.1111/j.1476-5381.2012.01972.x
[27]	Ibanez B, James S, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39: 119−177. doi: 10.1093/eurheartj/ehx393
[28]	Rossello X, Raposeiras-Roubin S, Latini R, et al. Rationale and design of the pragmatic clinical trial tREatment with Beta-blockers after myOcardial infarction withOut reduced ejection fracTion (REBOOT). Eur Heart J Cardiovasc Pharmacother 2022; 8: 291−301. doi: 10.1093/ehjcvp/pvab060
[29]	Wang M, Liu J, Liu J, et al. Association between early oral β-blocker therapy and in-hospital outcomes in patients with ST-elevation myocardial infarction with mild-moderate heart failure: findings from the CCC-ACS project. Front Cardiovasc Med 2022; 9: 828614. doi: 10.3389/fcvm.2022.828614
[30]	Goldberger JJ, Bonow RO, Cuffe M, et al. Beta-blocker use following myocardial infarction: low prevalence of evidence-based dosing. Am Heart J 2010; 160: 435−442.e1. doi: 10.1016/j.ahj.2010.06.023
[31]	Kukin A, Noel ZR, Watson K. Through the decades: β-blocker use and outcomes in acute coronary syndromes. Cardiol Rev 2018; 26: 157−166. doi: 10.1097/CRD.0000000000000197
[32]	Zhang H, Masoudi FA, Li J, et al. National assessment of early β-blocker therapy in patients with acute myocardial infarction in China, 2001–2011: the China Patient-centered Evaluative Assessment of Cardiac Events (PEACE)-retrospective AMI study. Am Heart J 2015; 170: 506−515.e1. doi: 10.1016/j.ahj.2015.05.012
[33]	Li D, Dong W, Chen Y, et al. [Effect of pathway training on rest heart rate and the application of β-blocker in coronary heart disease patients: an open-label, multi-center, prospective study]. Zhonghua Yi Xue Za Zhi 2015; 95: 2272−2276. [In Chinese]. doi: 10.3760/cma.j.issn.0376-2491.2015.28.007
[34]	Hjalmarson A, Elmfeldt D, Herlitz J, et al. Effect on mortality of metoprolol in acute myocardial infarction. A double-blind randomised trial. Lancet 1981; 2: 823−827. doi: 10.1016/s0140-6736(81)91101-6
[35]	Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45, 852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366: 1622−1632. doi: 10.1016/S0140-6736(05)67661-1
[36]	Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo-controlled international trial. The MIAMI Trial Research Group. Eur Heart J 1985; 6: 199−226.
[37]	Randomised trial of intravenous atenolol among 16, 027 cases of suspected acute myocardial infarction:ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet 1986; 2: 57−66.
[38]	Ko DT, Hebert PR, Coffey CS, et al. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA 2002; 288: 351−357. doi: 10.1001/jama.288.3.351
[39]	Arnold SV, Spertus JA, Masoudi FA, et al. Beyond medication prescription as performance measures: optimal secondary prevention medication dosing after acute myocardial infarction. J Am Coll Cardiol 2013; 62: 1791−1801. doi: 10.1016/j.jacc.2013.04.102
[40]	Everly MJ, Heaton PC, Cluxton RJ Jr. Beta-blocker underuse in secondary prevention of myocardial infarction. Ann Pharmacother 2004; 38: 286−293. doi: 10.1345/aph.1C472
[41]	Viskin S, Kitzis I, Lev E, et al. Treatment with beta-adrenergic blocking agents after myocardial infarction: from randomized trials to clinical practice. J Am Coll Cardiol 1995; 25: 1327−1332. doi: 10.1016/0735-1097(94)00552-2
[42]	Gislason GH, Rasmussen JN, Abildstrøm SZ, et al. Long-term compliance with beta-blockers, angiotensin-converting enzyme inhibitors, and statins after acute myocardial infarction. Eur Heart J 2006; 27: 1153−1158. doi: 10.1093/eurheartj/ehi705
[43]	Goldberger JJ, Bonow RO, Cuffe M, et al. Effect of beta-blocker dose on survival after acute myocardial infarction. J Am Coll Cardiol 2015; 66: 1431−1441. doi: 10.1016/j.jacc.2015.07.047
[44]	Allen JE, Knight S, McCubrey RO, et al. β-blocker dosage and outcomes after acute coronary syndrome. Am Heart J 2017; 184: 26−36. doi: 10.1016/j.ahj.2016.10.012
[45]	Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371: 1839−1847. doi: 10.1016/S0140-6736(08)60601-7
[46]	Butler J, Arbogast PG, BeLue R, et al. Outpatient adherence to beta-blocker therapy after acute myocardial infarction. J Am Coll Cardiol 2002; 40: 1589−1595. doi: 10.1016/S0735-1097(02)02379-3
[47]	Yang N, Liu J, Liu J, et al. Performance on management strategies with class I recommendation and a level of evidence among hospitalized patients with non-ST-segment elevation acute coronary syndrome in China: findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project. Am Heart J 2019; 212: 80−90. doi: 10.1016/j.ahj.2019.02.012
[48]	Hao Y, Zhao D, Liu J, et al. Performance of management strategies with class I recommendations among patients hospitalized with ST-segment elevation myocardial infarction in China. JAMA Cardiol 2022; 7: 484−491. doi: 10.1001/jamacardio.2022.0117