title: Has the ClOpidogrel and Metoprolol in Myocardial Infarction Trial (COMMIT) of early β-blocker use in acute coronary syndromes impacted on clinical practice in Canada? Insights from the Global Registry of Acute Coronary Events (GRACE).
abstract: BACKGROUND
  The COMMIT/CCS-2 trial, published in 2005, demonstrated no net benefit of early β-blocker (BB) therapy in acute coronary syndromes (ACS). We sought to assess the short-term impact of this landmark trial by comparing the use of early BB therapy in patients with a broad spectrum of ACS before and after 2005.
  
  
  METHODS
  Using data from the Global Registry of Acute Coronary Events and Canadian Registry of Acute Coronary Events, we compared the rates of BB use within the first 24 hours of presentation in the periods 1999 to 2005 and 2006 to 2008, after stratifying patients by the type of ACS (ST-segment elevation myocardial infarction [STEMI] and non-ST-segment elevation ACS [NSTEACS]) and clinical presentation.
  
  
  RESULTS
  Of the 14,231 patients with ACS, 77.7% received BB therapy within 24 hours of presentation (78.5% and 77.4% in the STEMI and NSTEACS groups, respectively). The early use of BB declined in the STEMI group (80.3% to 76.7%, P = .005) but increased in the NSTEACS group (75.4% to 78.9%, P < .001) after 2005. Long-term BB use, higher systolic blood pressure, and higher heart rate were independent predictors of early BB use. Conversely, patients who were female, older, Killip class >1, and had cardiac arrest at presentation were less likely to receive early BB. Multivariable analysis showed a trend toward lower use of BB among patients with STEMI (adjusted odds ratio 0.76, 95% CI 0.57-1.00, P = .055) and a trend toward more frequent BB use among patients with NSTEACS (adjusted odds ratio 1.22, 95% CI 0.96-1.55, P = .11) after 2005. The temporal trends in the early use of BB differed between patients with STEMI and patients with NSTEACS (P for interaction with period <.001).
  
  
  CONCLUSIONS
  Most patients with STEMI or NSTEACS were treated with early BB therapy. In accordance with the COMMMIT/CCS-2 trial, patients with lower systolic blood pressure and higher Killip class in the "real world" less frequently received early BB therapy. Since the publication of COMMIT/CCS-2, there has been no significant change in the use of BB in patients with STEMI or NSTEACS after controlling for their clinical characteristics.
authors.affiliation: Division of Cardiology, Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Edwards
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
authors.forename: Raymond T
authors.initials: RT
authors.lastname: Yan
authors.forename: Robert C
authors.initials: RC
authors.lastname: Welsh
authors.forename: Jan M
authors.initials: JM
authors.lastname: Kornder
authors.forename: J Paul
authors.initials: JP
authors.lastname: Deyoung
authors.forename: Denis
authors.initials: D
authors.lastname: Chauret
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Picard
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D000319:Adrenergic beta-Antagonists; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D000077144:Clopidogrel; D005260:Female; D006801:Humans; D008297:Male; D008790:Metoprolol / Q000627:therapeutic use*; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D012042:Registries; D012189:Retrospective Studies; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D000319:Adrenergic beta-Antagonists; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D008790:Metoprolol; D013988:Ticlopidine