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Vol. 40. Núm. 10.
Páginas 813-814 (Outubro 2021)
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Vol. 40. Núm. 10.
Páginas 813-814 (Outubro 2021)
Letter to the Editor
Open Access
Reply to letter “Beta-blockers in acute coronary syndrome patients: The concept of ‘gradient of benefit”’
Resposta à Carta «Beta-bloquantes no doente pós-SCA: o conceito de gradiente de benefício»
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Jesús Velásquez-Rodrígueza, Manuel Martínez-Sellésa,b,
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mmselles@secardiologia.es

Corresponding author.
a Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
b Universidad Complutense, Universidad Europea, Madrid, Spain
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Rev Port Cardiol. 2021;40:811-210.1016/j.repc.2021.05.009
Fernando Montenegro Sá, João Morais
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We would like to thank Fernando Montenegro Sá and João Morais for their interest in our paper.1 Beta-blockers are indicated after ST-segment elevation myocardial infarction (STEMI) in patients with left ventricular ejection fraction (LVEF) ≤40% (class I recommendation, level of evidence A) but in those with LVEF >40% the benefit is not clear (class IIa, level B).2 We agree that in patients in the 40-50% range beta-blockers appear more likely to help than to harm, due to their moderate probability of future events. The gradient of benefit means that beta-blockers should probably not be used in very low risk STEMI,3,4 in which the risk of cardiovascular events is extremely small in the near future. In addition, beta-blockers should be avoided in high-risk patients in whom side effects will probably occur, as in those with hypotension, acute heart failure,5 or shock6 (Figure 1).

Figure 1.

The gradient of benefit of beta-blockers (BB) according to the risk of future cardiovascular (CV) events and the risk of drug side effects in patients with ST-segment elevation myocardial infarction.

(0,08MB).

Further studies are needed to better identify STEMI patients who might benefit from beta-blockers, taking into consideration not only LVEF, but also other factors associated with prognosis that might improve with this treatment. For instance, endothelial dysfunction is common in STEMI7 and beta-blockers improve microvascular function.8 This is also the case with atrial fibrillation.9,10 Most studies of beta-blockers in STEMI were performed in an era when the rate of primary angioplasty was low and heart failure and mechanical complications were frequently seen.11 The current scenario is different and extrapolation of previous data could lead to overuse of these drugs. In the Description of Acute Myocardial Infarction: Management, New Therapies and Evolution (DIAMANTE) registry, 86% of our patients received beta-blockers.1 Finally, regarding dosage, Mars et al.12 have recently shown that target dose is not associated with cardiovascular outcomes, and Goldberger et al.13 even suggest that patients treated with 12.5-25% of the target dose may have enhanced survival compared with other doses.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
J. Velásquez-Rodríguez, V. Bruña, L. Vicent, et al.
Influence of left ventricular systolic function on the long-term benefit of beta-blockers after ST-segment elevation myocardial infarction.
Rev Port Cardiol, 40 (2021), pp. 285-290
[2]
B. Ibanez, S. James, S. Agewall, 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, 39 (2018), pp. 119-177
[3]
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Very low risk ST-segment elevation myocardial infarction? It exists and may be easily identified.
Int J Cardiol, 228 (2017), pp. 615-620
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Short-term and long-term validation of the fastest score in patients with ST-elevation myocardial infarction after primary angioplasty.
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[6]
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[9]
V. Bruña, J. Velásquez-Rodríguez, M.J. Valero-Masa, et al.
Prognostic of interatrial block after an acute ST-segment elevation myocardial infarction.
Cardiology, 142 (2019), pp. 109-115
[10]
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Effect of beta-blockers on the risk of atrial fibrillation in patients with acute myocardial infarction.
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[11]
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Temporal trends in mechanical complications of acute myocardial infarction in the elderly.
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[12]
K. Mars, J. Wallert, C. Held, et al.
Association between β-blocker dose and cardiovascular outcomes after myocardial infarction: insights from the SWEDEHEART registry.
Eur Heart J Acute Cardiovasc Care, 10 (2021), pp. 372-379
[13]
J.J. Goldberger, H. Subačius, O.C. Marroquin, OBTAIN (Outcomes of Beta-Blocker Therapy After Myocardial Infarction) Investigators, et al.
One-year landmark analysis of the effect of beta-blocker dose on survival after acute myocardial infarction.
J Am Heart Assoc, 10 (2021), pp. e019017
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