Medical Bulletin 03/ September /2024

Here are the top medical news of the day:

Does Continuing Beta-Blockers After a Heart Attack Make a Difference? New Study Sheds Lights

New research presented at ESC Congress 2024 found that stopping beta-blocker treatment after a heart attack doesn’t improve patient outcomes or quality of life compared to continuing the medication(1).

The open-label, non-inferiority, randomised ABYSS trial, conducted by the ACTION Group, included patients with a prior myocardial Infarction(MI) taking long-term beta-blockers, with a left ventricular ejection fraction of at least 40% and no cardiovascular events in the previous 6 months(2). Participants were randomised (1:1) to interrupt or continuing their β-blocker medication.

The main goal of the study was to evaluate if stopping beta-blocker therapy was not worse than continuing it(3), based on a combination of death, non-fatal heart attacks, non-fatal strokes, or hospitalizations for heart-related issues, measured over at least one year. Non-inferiority was defined as a difference of less than 3 percentage points between the two groups. Additionally, the study looked at changes in quality of life, using the European Quality of Life–5 Dimensions questionnaire as a measure.

In total 3,698 patients were randomised from 49 sites in France. The mean age was 64 years and 17% were female. The median time between the last myocardial Infarction(MI) and randomisation was 2.9 years.

In the study, death rates were 4.1% in the group that stopped beta-blockers and 4.0% in the group that continued them. Heart attacks occurred in 2.5% of the interruption group and 2.4% of the continuation group(4). However, hospitalizations for heart-related issues were higher in the interruption group (18.9%) compared to the continuation group (16.6%).

Additionally, stopping beta-blockers led to higher systolic and diastolic blood pressure and heart rate at 6 months and throughout the study period(5). There was no improvement in quality of life for those who stopped the medication.

Reference”: Beta blocker interruption in patients with prior myocardial infarction: results of the ABYSS trial and effect on blood pressure and heart rate control’ discussed during Hot Line 1 on Friday 30 August in room London.

No Benefit to Fasting Before Catheterization Procedures: SCOFF Trial

New research presented at ESC Congress 2024 shows that fasting or not fasting before cardiac catheterization procedures with conscious sedation does not affect the rate of complications(6).

The SCOFF trial, a randomized study with an open-label design and blinded endpoints, evaluated whether not fasting before cardiac catheterization procedures requiring conscious sedation was as effective as fasting(7).

Patients scheduled for coronary angiography, coronary interventions, or procedures involving cardiac implantable electronic devices(8) were included. They were randomly assigned to either fast before the procedure (no solid food for 6 hours and no clear liquids for 2 hours) or to eat normally with no strict fasting requirements.

The main combined measure of the study focused on hypotension, aspiration pneumonia, hyperglycemia, and hypoglycemia, evaluated using a Bayesian method.

Secondary measures included contrast-induced nephropathy, new admissions to intensive care following the procedure(9), new ventilation needs post-procedure, new ICU admissions, readmissions within 30 days, mortality within 30 days, 30-day pneumonia rates, and patient satisfaction before the procedure.

In total, 716 patients were recruited, the mean age was 69 years and 35% were female. As expected, fasting times were longer with fasting compared with no fasting (solid fasting 13.2 hours vs. 3.0 hours, clear liquid fasting 7.0 hours vs. 2.4 hours).

The results showed that not fasting before the procedure is just as safe as fasting(10). In fact, not fasting might even be slightly better for avoiding complications, with a 99.1% chance of being more effective. On average, the risk of complications was 7.1% lower for those who didn’t fast compared to those who did. For every 14 patients who don’t fast, one fewer person experienced a complication.

When looking at secondary outcomes, there were no noticeable differences between fasting and not fasting. However, patients who didn’t fast reported significantly higher satisfaction.

Reference: SCOFF - Fasting or no fasting before cardiac catheterisation procedures’ discussed during Hot Line 8 on Sunday 1 September in room London.

Finerenone Reduces Heart Failure Events and Cardiovascular Deaths: FINEARTS-HF trial

Recent research presented at ESC Congress 2024 reveals that finerenone decreased the incidence of heart failure events and cardiovascular deaths in patients with heart failure (11)and either mildly reduced ejection fraction (HFmrEF) or preserved ejection fraction (HFpEF).

The FINEARTS-HF trial was a double-blind, randomized study involving patients with heart failure (NYHA functional class II–IV) and a left ventricular ejection fraction (LVEF) of 40% or higher(12). Participants were also required to be 40 years of age or older, have elevated natriuretic peptide levels, and show signs of structural heart disease.

Eligible patients were randomly assigned to receive either finerenone (up to 40 mg daily, based on their initial estimated glomerular filtration rate [eGFR]) or a placebo(13).

The main goal of the study was to assess a combination of worsening heart failure events (both new and recurring) and cardiovascular death.

Secondary goals included overall mortality and a composite kidney outcome, which encompassed a sustained 50% or more drop in eGFR, a sustained decline in eGFR to below 15 ml/min/1.73 m², or the start of chronic dialysis or kidney transplantation.

In total, 6,001 patients, mean age was 72 years and 46% were women. Finerenone significantly lowered the rate of worsening heart failure and cardiovascular death compared to a placebo over a median of 32 months.

Specifically, there were 1,083 worsening heart failure events in the finerenone group versus 1,283 in the placebo group, showing a 16% reduction in events with finerenone. Total worsening heart failure events were also lower with finerenone (842 events) compared to placebo (1,024 events).

Overall, Scientists concluded that finerenone reduce the heart failure events and cardiovascular death in patients with reduced ejection fraction (HFmrEF) or preserved ejection fraction (HFpEF).

Reference: Finerenone reduced heart failure (HF) events and cardiovascular death in patients with HF and mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF), according to late-breaking research presented in a Hot Line session today at ESC Congress 2024.

Study Shows No Advantage of Nighttime Blood Pressure Medication Over Morning Dosing

In two trials involving frail elderly patients, taking blood pressure-lowering medications in the evening didn't offer any clinical benefits compared to taking them in the morning(14), according to new research presented at ESC Congress 2024.

In the BedMed trial, Canadian patients without glaucoma who were taking at least one daily blood pressure medication were randomly assigned to take their medications either in the morning or at bedtime(15). The main goal was to see if the timing affected major health problems like death, stroke, heart attack, or heart failure. Secondary goals included checking for unexpected hospital visits and issues related to vision, cognitive function, or fractures.

The BedMed-Frail trial was similar but focused on patients in Canadian long-term care facilities. These participants were assigned to either bedtime dosing or their usual morning dosing(15). Additional secondary goals included looking at skin ulcers and changes in cognitive function.

In the BedMed trial, 3,357 adults with an average age of 67 years (56% female) were randomly assigned to take their blood pressure medications either at bedtime or in the morning(16). There were no differences in safety outcomes or rates of hospitalizations and emergency department visits between the two groups.

In the BedMed-Frail trial, 776 participants with an average age of 88 years (72% female) were assigned to take their blood pressure medications either at bedtime or in the morning. Over an average of 415 days, major health problems occurred in 40.6% of those who took their medications at bedtime and in 41.9% of those who took them in the morning. There were no significant differences in other outcomes between the groups, except that taking medications at bedtime was associated with fewer unexpected hospital visits or emergency department trips.

Reference: The BedMed and BedMed-Frail randomised controlled trials - Effect of antihypertensive timing on mortality and morbidity’ will be discussed during Hot Line 2 on Saturday 31 August in room London.

Single-Pill Combination of Four Blood Pressure Medications Outperforms Three-Medication Pill: QUADRO Trial Reveals

New research presented at ESC Congress 2024 reveals that a single pill combining four blood pressure-lowering medications is significantly more effective than a pill with just three medications(17).

In the QUADRO trial, patients with resistant high blood pressure(18) first went through an 8-week period where they took a combination of three medications—perindopril, indapamide, and amlodipine—at the highest doses they could tolerate.

If their blood pressure remained high after this period (140 mmHg or more at the doctor's office or 130 mmHg or more over 24 hours), and they were following the treatment, they were then randomly assigned to either keep taking the three medications or switch to a single pill that combined perindopril, indapamide, amlodipine, and bisoprolol.

Both groups took the same number of pills daily to keep the study blind. The main measure of success was the change in blood pressure at the doctor’s office, while secondary measures included monitoring blood pressure over 24 hours, at home, and in the office(19).

In the study, 183 patients from 49 centers across 13 countries participated. The average age was 57 years, and 47% were women. Initially, their average office blood pressure was 150.3 mmHg for systolic (top number) and 90.0 mmHg for diastolic(20) (bottom number).

After 8 weeks, patients taking the single-pill combination of four medications saw their average office systolic blood pressure drop by 20.67 mmHg, compared to a drop of 11.32 mmHg for those taking the three-medication combination. The difference was significant, favoring the four-medication pill.

There was also a significant improvement in the average 24-hour ambulatory systolic blood pressure and the office diastolic blood pressure for those on the four-medication pill compared to the three-medication group(21).

Overall, 66.3% of patients on the four-medication pill achieved target blood pressure control, compared to 42.7% of those on the three-medication pill. For normal blood pressure over 24 hours(21), 51.2% of those on the four-medication pill met the target, versus 20.7% of those on the three-medication pill. At home, 60.7% of patients on the four-medication pill achieved normal blood pressure, compared to 25.4% of those on the three-medication pill.

Reference: QUADRO - A single 4-drug combination in hypertension’ will be discussed during Hot Line 2 on Saturday 31 August in room London.