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BACKGROUND: The benefit of beta-blockers after myocardial infarction in patients with a preserved left ventricular ejection fraction (LVEF) is unclear.

METHODS: We conducted a meta-analysis at the individual-patient level using data from five open-label trials that randomly assigned patients with recent myocardial infarction, no other indications for beta-blocker therapy, and an LVEF of at least 50% to receive beta-blocker therapy or no beta-blocker therapy. The primary end point was a composite of death from any cause, myocardial infarction, or heart failure. Event rates were analyzed with a one-stage fixed-effects Cox proportional-hazards model.

RESULTS: A total of 17,801 patients were included from the REBOOT (7459 patients), REDUCE-AMI (4967 patients), BETAMI (2441 patients), DANBLOCK (2277 patients), and CAPITAL-RCT (657 patients) trials. Of these 17,801 patients, 8831 (49.6%) were assigned to receive a beta-blocker and 8970 (50.4%) were assigned to receive no beta-blocker. During a median follow-up of 3.6 years (interquartile range, 2.3 to 4.6), a primary-end-point event occurred in 717 patients (8.1%) in the beta-blocker group and 748 patients (8.3%) in the no-beta-blocker group (hazard ratio, 0.97; 95% confidence interval [CI], 0.87 to 1.07; P = 0.54). Death from any cause occurred in 335 patients in the beta-blocker group and 326 patients in the no-beta-blocker group (hazard ratio, 1.04; 95% CI, 0.89 to 1.21); myocardial infarction occurred in 360 and 407 patients, respectively (hazard ratio, 0.89; 95% CI, 0.77 to 1.03); and heart failure occurred in 75 and 87 patients (hazard ratio, 0.87; 95% CI, 0.64 to 1.19).

CONCLUSIONS: In this meta-analysis including individual-patient data from five randomized trials, beta-blocker therapy did not reduce the incidence of death from any cause, myocardial infarction, or heart failure in patients with an LVEF of at least 50% after myocardial infarction without other indications for beta-blockers. (Funded by Centro Nacional de Investigaciones Cardiovasculares Carlos III and others; PROSPERO database number, CRD420251119176.).

BACKGROUND: Renal dysfunction increases cardiovascular (CV) risk. We compared cystatin C-based estimated glomerular filtration rate (eGFRcys), creatinine-based eGFR (eGFRcr), and their ratio (eGFRcys/eGFRcr) in relation to major adverse cardiovascular events (MACE) and all-cause mortality in chronic coronary syndrome, assessing the added prognostic value of the eGFRratio.

METHODS: In this post hoc analysis of 14,513 Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy trial patients, we investigated associations between baseline eGFRcys, eGFRcr, their ratio, and MACE and all-cause death using Cox regression models, unadjusted and adjusted for eGFRcys, eGFRcr, and their combination. Discrimination was assessed using Harrell's C-index; added value by the fraction of new information (FNI).

RESULTS: Median age was 65 years; 82% were male. Median eGFRcys was 77 (interquartile range [IQR]: 61-94) and eGFRcr 79 (IQR: 65-91) mL/min/1.73 m². Over 3.7 years, 1449 MACE and 1063 deaths occurred. Lower eGFR values and eGFRratio were associated with increased MACE risk, primarily driven by CV death. For eGFRcys 60 versus 90, the hazard ratio (HR) for MACE adjusted for eGFRcr was 1.77 (95% CI: 1.49-2.09, FNI 54%). In contrast, eGFRcr adjusted for eGFRcys showed no positive association (HR 0.82, 95% CI: 0.68-0.97, FNI 3%). A lower eGFRratio was linked to higher MACE risk (HR 1.99, 95% CI: 1.80-2.21), which remained after eGFRcr adjustment (HR 1.89, 95% CI: 1.70-2.10, FNI 54%) but was attenuated after eGFRcys adjustment (HR 1.29, 95% CI: 1.13-1.46, FNI 5%).

CONCLUSION: In chronic coronary syndrome, lower eGFRcys, eGFRcr, and eGFRratio were associated with higher MACE and mortality risk. eGFRcys had the strongest association; eGFRcr and eGFRratio added limited incremental value.

Background: Patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) or Takotsubo syndrome (TS) often suffer from poor mental health and low quality-of-life post event, with no current evidence-based treatments available. This study aimed to evaluate the effects of an internet-delivered cognitive behavioral therapy program on stress and anxiety symptoms in patients diagnosed with myocardial infarction with nonobstructive coronary arteries or TS.

Methods: A parallel, multicenter, randomized controlled trial with a wait-list control group was conducted. Patients with elevated symptoms of stress or anxiety were included (the 14-item perceived stress scale ≥25 or hospital anxiety and depression scale, anxiety subscale ≥8). The primary outcome was normalized stress and anxiety levels 10 to 12 weeks after randomization. Secondary outcomes included normalized stress and anxiety separately and symptoms as continuous measures.

Results: A total of 88 patients were randomized (treatment: 45, control: 43). The treatment group showed a greater, though not statistically significant proportion of normalized patients (odds ratio, 2.37 [95% CI, 0.88-6.38], P=0.09). Secondary analyses indicated treatment effects on anxiety normalization and on symptoms as continuous measures (effect sizes: d=0.44-0.67). There was also an interaction between treatment and diagnosis (TS versus non-TS), favoring a treatment effect in TS patients (P=0.016).

Conclusions: The patient-tailored internet-delivered cognitive behavioral therapy program reduced stress and anxiety symptoms in patients with myocardial infarction with nonobstructive coronary arteries or TS and normalized anxiety symptoms in a greater proportion of treated patients than controls. Exploratory analyses indicated that patients with TS may experience greater benefit from the internet-delivered cognitive behavioral therapy intervention, but this warrants further research.

Objective: Cardiac anxiety (CA) is common and has been associated with increased morbidity and mortality in patients after acute myocardial infarction (AMI). While beta-blockers are widely used in secondary prevention after AMI and have proven anxiolytic effects among psychiatric patients, little is known of their effect on CA among AMI-patients. This study aimed to investigate the effect of beta-blockers on CA in post-AMI patients with preserved cardiac function. Methods: In this parallel-group, open-label, registry-based randomized clinical trial, assessments with the Cardiac Anxiety Questionnaire (CAQ) were obtained at hospitalization and at two follow-up points (6-10 weeks and 12-14 months) after AMI. Analyses were based on the intention-to-treat (ITT) principle using multiple linear regression, calculating both short- and long-term effects. Stratified analyses were also conducted in groups with low, moderate and high baseline values on the CAQ. Results: From August 2018 through June 2022, 806 patients were enrolled. In the main analysis, no treatment effect of beta-blocker on CA was observed at either follow-up. In stratified analyses, the levels of CA symptoms were lower for those randomized to beta-blocker treatment in the group with moderate baseline CA, at follow-up 2 (beta = -0.12; 95 % CI -0.22, -0.02; P = 0.016). Conclusions: This trial found no evidence of an effect of beta-blockers on CA among AMI-patients with preserved cardiac function. However, lacking information on beta-blocker adherence limits the possibility of drawing firm conclusions. Furthermore, there might be a differential effect among patients depending on their baseline CA level, as patients with moderate baseline CA randomized to beta-blockers reported lower CA during follow-up than controls.

Background Optimal antithrombotic therapy and its duration, whether triple therapy with dual antiplatelets plus oral anticoagulant (OAC), or dual antithrombotic therapy with an antiplatelet plus OAC, is uncertain for patients with myocardial infarction (MI) and atrial fibrillation (AF).

Methods Patients registered in SWEDEHEART (Swedish Web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies) for their first MI between 2011 and 2021 with a history or new-onset AF were included (n=26 574). Linkage between SWEDEHEART and Swedish administrative health databases was performed, and pseudonymised data analysed.

Results Over time, OAC use at discharge after MI tripled from 27% in 2011 to 77% in 2021, with direct OACs (DOACs) largely replacing warfarin, predominantly in combination with a single antiplatelet. The strongest factors for initiating OAC therapy were the performance of coronary angiography (OR 1.53 (1.40-1.68)), and percutaneous coronary intervention (OR 1.49 (1.39-1.61)). However, the year of the MI was the most predictive variable associated with OAC initiation, with an OR of 9.31 (7.92-10.95) in 2021 compared with 2011. The clinical factors associated with lower likelihood of OAC initiation were dementia, liver disease, cancer and ST-elevation MI (STEMI) versus non-STEMI.

Conclusions Use of OAC has increased over the years in patients with MI and concurrent AF, primarily driven by the increased adoption of DOACs. Additionally, there has been a shift in antithrombotic combinations, with most patients in recent years receiving DOAC in combination with a single antiplatelet, reflecting the nationwide implementation of recent evidence and guidelines. However, significant variation in antithrombotic therapy strategies remains.

BACKGROUND Hemodynamically obstructive coronary plaques may contain more vulnerable plaque characteristics than nonobstructive lesions. OBJECTIVES The authors aimed to assess whether pressure-wire-based physiologic indices in nonculprit lesions are associated with vulnerable plaque characteristics. METHODS In the PROSPECT II study, patients with recent myocardial infarction underwent coronary angiography and culprit lesion percutaneous coronary intervention plus combined near-infrared spectroscopy and intravascular ultrasound assessment of all 3 coronary arteries. Instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements were performed in intermediate lesions with angiographic stenosis >40%. RESULTS Among 898 patients, 319 angiographically intermediate lesions in 275 patients had matched intravascular ultrasound/near-infrared spectroscopy and FFR/iFR measurements; 96 (30.1%) lesions were physiologically significant (FFR <= 0.80 or iFR <= 0.89) and 223 (69.9%) were not. Physiologically significant lesions, compared with those that were not, more likely had a minimal lumen area <= 4.0 mm(2) (96.9% vs 83.9%), plaque burden >= 70% (92.7% vs 71.3%) and maximum lipid core burden index in any 4 mm segment of the lesion >= 324.7 (57.0% vs 45.4%). By multivariable analysis, lesion location in the left anterior descending artery, small minimal lumen area, and larger plaque burden were independently associated with physiologic significance, whereas maximum lipid core burden index in any 4 mm segment of the lesion was not. CONCLUSIONS In patients with recent myocardial infarction, angiographically intermediate but physiologically significant coronary lesions were more likely to have high-risk vulnerable plaque features compared with nonphysiologically significant stenoses. However, coronary lesions without physiological significance also had a moderate-to-high prevalence of high-risk plaque characteristics, which may explain the residual risk associated with conservative noninterventional management of these lesions.

Aims: Improved dietary habits are important for successful secondary prevention after myocardial infarction (MI), with counselling and support on healthy dietary habits constituting a cornerstone of cardiac rehabilitation (CR). However, there is limited knowledge on how to optimize CR organization to motivate patients to adopt healthy dietary habits. We aimed to explore associations between CR programme structure, processes, and self-reported dietary habits 1 year post-MI.

Methods and results: Organizational data from 73 Swedish CR centres and patient-level data from 5248 CR patients were analysed using orthogonal partial least squares discriminant analysis to identify predictors for healthy dietary habits. Variables of importance for the projection (VIP) values exceeding 0.80 were considered meaningful. Key predictors included the CR centre having a medical director [VIP (95% confidence interval)] [1.86 (1.1-2.62)], high self-reported team spirit [1.63 (1.29-1.97)], nurses have formal training in counselling methods [1.20 (0.75-1.65)], providing discharge information on risk factors [2.23 (1.82-2.64)] and lifestyle [1.81 (1.31-2.31)], time dedicated to patient interaction during follow-up [1.60 (0.80-2.40)], and centres aiming for patients to have the same nurse throughout follow-up [1.54 (1.17-1.91)]. The more positive predictors a CR centre reported to follow, the further improvement in patient-level dietary habits, were analysed by multivariable regression analysis [odds ratio for each additional positive predictor reported 1.03 (1.02-1.05), P < 0.001].

Conclusion: Several variables related to CR structure and processes were identified as predictors for patients reporting healthier dietary habits. These findings offer guidance for CR centres in resource allocation and optimizing patient benefits of CR attendance.

Clinical endpoint classification (CEC)-that is, evaluation of clinical events using pre-defined criteria-is commonly conducted in clinical trial operations to ensure systematic and consistent assessment of endpoints needed to assess the intervention's safety and efficacy. This is particularly relevant for heart failure (HF) trials given the subjective decision-making around hospitalizations and variation in how worsening HF events are managed (both in hospital and in ambulatory settings). Several CEC strategies have been adopted to address the growing need for pragmatic clinical trials that enhance generalizability and minimize research burden on trial sites and patients. This review summarizes common CEC strategies including the traditional approach, investigator-reported endpoints, CEC using real-world data and CEC utilizing large language models. We summarize CEC strategies used in recent HF pragmatic trials and present challenges and considerations for CEC in HF pragmatic trials from the selection of clinical endpoints and data collection to CEC.