ESC Congress 2017 In Review – Focus on CAD&ACS - 16

Late-Breaking Science

placebo groups in any of the subgroups comparisons,
including patients with anterior infarct versus non-anterior infarct and those with previous β-blocker therapy
versus those without (Figure 1).
Figure 1. Prespecified Subgroup Analysis
Metoprolol

Placebo

24/312 (7.7%)

23/317 (7.3%)

1.07 (0.59-1.93)

Female

5/77 (6.5%)

4/74 (5.4%)

1.22 (0.31-4.71)

Male

19/235 (8.1%)

19/243 (7.8%)

1.04 (0.53-2.01)

Anterior infarct

11/145 (7,6%)

9/153 (5.9%)

1.31 (O.53-3.27)

Non anterior infarct

12/147 (8.2%)

12/139 (8.6%)

0.94 (0.41-2.17)

All patients

Odds Ratio (95% CI)

Gender

Interacton P value .84
Location of MI

Interacton P value .60
β-blocker use before inclusion
β-blocker

6/52 (12%)

9/49 (18%)

No β-blocker

17/256 (6.6%)

14/265 (5.3%)

O.58 (0.19-1.77)

Interacton P value .25

1.28 (0.62-2.64)

Time between first bolus study medication and start PCI
Time < = median

9/121 (7.4%}

10/142 (7.0%)

1.06 (0.42-2.70)

Time < median

12/142 (8.5%)

11/119 (9.2%)

0.91 (0.38-2.14)

Interacton P value .81
0.1

Favours Metoprolol

1

10

Favours Placebo

MI, myocardial infarction.
Reproduced with permission from V Roolvink, MD.

The EARLY-BAMI trial was the largest β-blocker trial in
STEMI patients treated with primary PCI. According to Dr
Roolvink, the results did not confirm the effect observed
in the smaller METOCARD-CNIC trial. Comparing the
results of the 2 trials, a trend in MACE reduction was
observed at 6 months in METOCARD-CNIC versus no difference at 1 year in EARLY-BAMI. Significant reductions
in hospitalisation for heart failure (HF) and implantable
cardioverter defibrillator (ICD) implantation were found
in the METOCARD-CNIC trial at 6 months versus no difference at 1 year in EARLY-BAMI.
There were several differences in the METOCARDCNIC trial that might account for the different results.
METOCARD-CNIC only included anterior infarctions, had
a higher dose of metoprolol (15 mg vs 10 mg in EARLYBAMI), excluded patients on long-term β-blockers therapy
before admission, and had a longer time from β-blocker
treatment to primary PCI.
In conclusion, the EARLY-BAMI secondary analysis
found no difference at 1 year in MACE, re-admission for HF,
or ICD implantation between STEMI patients treated with
early pre-hospital IV metoprolol versus placebo. These findings reinforce that there remains no indication for routine
early intravenous of β-blocker therapy in acute MI, which
remains limited to use in patients with refractory angina or
hypertension. In contrast, oral β-blocker therapy remains
recommended within 24 hours of presentation.

16

October 2017

Empagliflozin Cuts Risk of Death
in T2D Patients After CABG
Written by Nicola Parry

Empagliflozin is a selective sodium-glucose cotransporter 2 inhibitor that reduces hyperglycemia in
patients with type 2 diabetes (T2D) by reducing renal
glucose reabsorption, and thereby increasing urinary
glucose excretion.
Subodh Verma, MD, PhD, FRCSC, University of
Toronto, Canada, reported data from an analysis of the
EMPA-REG OUTCOME trial, demonstrating that empagliflozin given in addition to standard of care markedly
reduced the rates of cardiovascular (CV) death, all-cause
mortality, and hospitalisation for HF (HHF) in patients
with T2D with a history of coronary artery bypass graft
(CABG) surgery. The analysis compared data from the
pooled empagliflozin dose groups (10 mg and 25 mg)
with data from the placebo group, in patients who
received ≥ 1 dose of the study drug.
The EMPA-REG OUTCOME trial had shown that
empagliflozin treatment in addition to standard care led
to substantial reductions in the risk of CV death (38%),
all-cause mortality (32%), and HHF (35%) compared
with placebo 6,314 patients with T2D and established
CV disease [Zinman B et al. N Engl J Med. 2015].
Overall, 25% of patients treated with empagliflozin
and 24% of those treated with placebo had a history of
CABG at baseline.
The investigators compared study outcomes between
the two treatment groups including: the 3-point major
adverse CV event (MACE) composite outcome of CV
death, non-fatal myocardial infarction (MI), and stroke; CV
death; all-cause mortality; HHF; stroke; MI; and incident or
worsening nephropathy. They used a time-to-first-event
approach and performed the analyses on the pooled
empagliflozin dose groups versus the placebo group.
Among 1,738 patients with a history of CABG (1,175
patients receiving empagliflozin), the 3-point MACE outcome was 10.6% in the pooled empagliflozin group compared with 13.3% in the placebo group.
Compared with placebo, empagliflozin treatment substantially decreased the incidence of CV death (3.0% vs
5.7%; HR, 0.52; 95% CI, 0.32 to 0.84), all-cause mortality
(5.1% vs 8.9%; HR, 0.57; 95% CI, 0.39 to 0.83), and HHF
(3.3% vs 6.7%; HR, 0.50; 95% CI, 0.32 to 0.77). Empagliflozin
treatment was also associated with a decreased incidence
of stroke (3.3% vs 2.7%), and MI (5.7% vs 7.1%).
According to Dr Verma, the size of the benefits in the
CABG subgroup was at least as large as what was found
in the main trial. These findings have important translational implications for secondary prevention after
CABG, he concluded.

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