Abstract
Besides its protective effect against neutrophil-mediated injury at reperfusion, intravenous (IV) metoprolol was recently shown to reduce the progression of ischemic injury in a pig model of ST-segment elevation myocardial infarction (STEMI). Here, we tested the hypothesis that IV metoprolol administration in humans with ongoing STEMI blunts the time‑dependent progression of ischemic injury assessed by serial electrocardiogram (ECG) evaluations before reperfusion. The METOCARD-CNIC trial randomized 270 anterior STEMI patients to IV metoprolol or control before reperfusion by percutaneous coronary intervention (PCI). In 139 patients (69 IV metoprolol, 70 controls), two ECGs were available (ECG-1 before randomization, ECG-2 pre-PCI). Between-group ECG differences were analyzed using univariate and multivariate regression models. No significant between-group differences were observed on ECG-1. On ECG-2, patients who received IV metoprolol had a narrower QRS than those in the control group (84 ms vs. 90 ms, p = 0.029), a lower prevalence of QRS distortion (10% vs. 26%, p = 0.017), and a lower sum of anterior and total ST-segment elevation (10.1 mm vs. 13.6 mm, p = 0.014 and 10.4 mm vs. 14.0 mm, p = 0.015, respectively). Adjusted analysis revealed similar results. Significant associations were observed between ECG-2 variables and cardiac magnetic resonance imaging measurements (extent of myocardial edema, infarct size, microvascular obstruction, and left-ventricular ejection fraction) after STEMI. In summary, IV metoprolol administration before reperfusion ameliorates ECG markers of myocardial ischemia in anterior STEMI patients. These data confirm that IV metoprolol is able to reduce ischemic injury and highlight the ability of ECG analysis to provide relevant real-time information on the effect of cardioprotective therapies before reperfusion.
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Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimsky P, Group ESCSD (2018) 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 39:119–177. https://doi.org/10.1093/eurheartj/ehx393
Ibanez B, Heusch G, Ovize M, Van de Werf F (2015) Evolving therapies for myocardial ischemia/reperfusion injury. J Am Coll Cardiol 65:1454–1471. https://doi.org/10.1016/j.jacc.2015.02.032
Rossello X, Lobo-Gonzalez M, Ibanez B (2019) Editor’s choice-pathophysiology and therapy of myocardial ischaemia/reperfusion syndrome. Eur Heart J Acute Cardiovasc Care 8:443–456. https://doi.org/10.1177/2048872619845283
Ibanez B, Aletras AH, Arai AE, Arheden H, Bax J, Berry C, Bucciarelli-Ducci C, Croisille P, Dall’Armellina E, Dharmakumar R, Eitel I, Fernandez-Jimenez R, Friedrich MG, Garcia-Dorado D, Hausenloy DJ, Kim RJ, Kozerke S, Kramer CM, Salerno M, Sanchez-Gonzalez J, Sanz J, Fuster V (2019) Cardiac MRI endpoints in myocardial infarction experimental and clinical trials: JACC scientific expert panel. J Am Coll Cardiol 74:238–256. https://doi.org/10.1016/j.jacc.2019.05.024
Heusch G (2020) Myocardial ischaemia-reperfusion injury and cardioprotection in perspective. Nat Rev Cardiol 17:773–789. https://doi.org/10.1038/s41569-020-0403-y
Rossello X, Ibanez B (2018) Infarct size reduction by targeting ischemic injury: back to square one. Circ Res 122:1041–1043. https://doi.org/10.1161/CIRCRESAHA.118.312939
Husser O, Bodi V, Sanchis J, Nunez J, Mainar L, Rumiz E, Lopez-Lereu MP, Monmeneu J, Chaustre F, Trapero I, Forteza MJ, Riegger GA, Chorro FJ, Llacer A (2010) The sum of ST-segment elevation is the best predictor of microvascular obstruction in patients treated successfully by primary percutaneous coronary intervention. Cardiovascular magnetic resonance study. Rev Esp Cardiol 63:1145–1154. https://doi.org/10.1016/s1885-5857(10)70228-0
Rodriguez-Palomares JF, Figueras-Bellot J, Descalzo M, Moral S, Otaegui I, Pineda V, Del Blanco BG, Gonzalez-Alujas MT, Evangelista Masip A, Garcia-Dorado D (2014) Relation of ST-segment elevation before and after percutaneous transluminal coronary angioplasty to left ventricular area at risk, myocardial infarct size, and systolic function. Am J Cardiol 113:593–600. https://doi.org/10.1016/j.amjcard.2013.11.007
Sejersten M, Ripa RS, Maynard C, Wagner GS, Andersen HR, Grande P, Mortensen LS, Clemmensen P (2006) Usefulness of quantitative baseline ST-segment elevation for predicting outcomes after primary coronary angioplasty or fibrinolysis (results from the DANAMI-2 trial). Am J Cardiol 97:611–616. https://doi.org/10.1016/j.amjcard.2005.09.099
Chavez-Gonzalez E, Rodriguez Jimenez AE, Moreno-Martinez FL (2017) QRS duration and dispersion for predicting ventricular arrhythmias in early stage of acute myocardial infraction. Med Intensiva 41:347–355. https://doi.org/10.1016/j.medin.2016.09.008
Hansen R, Frydland M, Moller-Helgestad OK, Lindholm MG, Jensen LO, Holmvang L, Ravn HB, Kjaergaard J, Hassager C, Moller JE (2017) Association between QRS duration on prehospital ECG and mortality in patients with suspected STEMI. Int J Cardiol 249:55–60. https://doi.org/10.1016/j.ijcard.2017.07.049
Buller CE, Fu Y, Mahaffey KW, Todaro TG, Adams P, Westerhout CM, White HD, van’t Hof AW, Van de Werf FJ, Wagner GS, Granger CB, Armstrong PW (2008) ST-segment recovery and outcome after primary percutaneous coronary intervention for ST-elevation myocardial infarction: insights from the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial. Circulation 118:1335–1346. https://doi.org/10.1161/CIRCULATIONAHA.108.767772
Syed MA, Borzak S, Asfour A, Gunda M, Obeidat O, Murphy SA, Gibbons RJ, Gourlay SG, Barron HV, Weaver WD, Hudson M (2004) Single lead ST-segment recovery: a simple, reliable measure of successful fibrinolysis after acute myocardial infarction. Am Heart J 147:275–280. https://doi.org/10.1016/j.ahj.2003.08.010
Kacmaz F, Maden O, Aksuyek S, Ureyen C, Alyan O, Erbay AR, Selcuk H, Ulusoy V, Balbay Y, Ilkay E (2008) Relationship of admission QRS duration and changes in QRS duration with myocardial reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy. Circ J 72:873–879. https://doi.org/10.1253/circj.72.873
Yusuf J, Das D, Mukhopadhyay S, Tyagi S (2018) Correlation of QRS duration with myocardial blush grade as a marker of myocardial reperfusion in primary percutaneous coronary intervention. Indian Heart J 70(Suppl 3):S359–S364. https://doi.org/10.1016/j.ihj.2018.10.412
Amanakis G, Kleinbongard P, Heusch G, Skyschally A (2019) Attenuation of ST-segment elevation after ischemic conditioning maneuvers reflects cardioprotection online. Basic Res Cardiol 114:22. https://doi.org/10.1007/s00395-019-0732-3
Kleinbongard P, Amanakis G, Skyschally A, Heusch G (2018) Reflection of cardioprotection by remote ischemic perconditioning in attenuated ST-segment elevation during ongoing coronary occlusion in pigs: evidence for cardioprotection from ischemic injury. Circ Res 122:1102–1108. https://doi.org/10.1161/CIRCRESAHA.118.312784
Heusch G, Kleinbongard P (2020) Is metoprolol more cardioprotective than other beta-blockers? Eur Heart J 41:4441–4443. https://doi.org/10.1093/eurheartj/ehaa764
Clemente-Moragon A, Gomez M, Villena-Gutierrez R, Lalama DV, Garcia-Prieto J, Martinez F, Sanchez-Cabo F, Fuster V, Oliver E, Ibanez B (2020) Metoprolol exerts a non-class effect against ischaemia-reperfusion injury by abrogating exacerbated inflammation. Eur Heart J 41:4425–4440. https://doi.org/10.1093/eurheartj/ehaa733
Garcia-Prieto J, Villena-Gutierrez R, Gomez M, Bernardo E, Pun-Garcia A, Garcia-Lunar I, Crainiciuc G, Fernandez-Jimenez R, Sreeramkumar V, Bourio-Martinez R, Garcia-Ruiz JM, Del Valle AS, Sanz-Rosa D, Pizarro G, Fernandez-Ortiz A, Hidalgo A, Fuster V, Ibanez B (2017) Neutrophil stunning by metoprolol reduces infarct size. Nat Commun 8:14780. https://doi.org/10.1038/ncomms14780
Garcia-Ruiz JM, Fernandez-Jimenez R, Garcia-Alvarez A, Pizarro G, Galan-Arriola C, Fernandez-Friera L, Mateos A, Nuno-Ayala M, Aguero J, Sanchez-Gonzalez J, Garcia-Prieto J, Lopez-Melgar B, Martinez-Tenorio P, Lopez-Martin GJ, Macias A, Perez-Asenjo B, Cabrera JA, Fernandez-Ortiz A, Fuster V, Ibanez B (2016) Impact of the timing of metoprolol administration during STEMI on infarct size and ventricular function. J Am Coll Cardiol 67:2093–2104. https://doi.org/10.1016/j.jacc.2016.02.050
Lobo-Gonzalez M, Galan-Arriola C, Rossello X, Gonzalez-Del-Hoyo M, Vilchez JP, Higuero-Verdejo MI, Garcia-Ruiz JM, Lopez-Martin GJ, Sanchez-Gonzalez J, Oliver E, Pizarro G, Fuster V, Ibanez B (2020) Metoprolol blunts the time-dependent progression of infarct size. Basic Res Cardiol 115:55. https://doi.org/10.1007/s00395-020-0812-4
Ibanez B (2020) Intravenous beta-blockers in STEMI: what you are about to do, do it quickly. Eur Heart J Acute Cardiovasc Care 9:459–461. https://doi.org/10.1177/2048872620950205
Ibanez B, Macaya C, Sanchez-Brunete V, Pizarro G, Fernandez-Friera L, Mateos A, Fernandez-Ortiz A, Garcia-Ruiz JM, Garcia-Alvarez A, Iniguez A, Jimenez-Borreguero J, Lopez-Romero P, Fernandez-Jimenez R, Goicolea J, Ruiz-Mateos B, Bastante T, Arias M, Iglesias-Vazquez JA, Rodriguez MD, Escalera N, Acebal C, Cabrera JA, Valenciano J, Perez de Prado A, Fernandez-Campos MJ, Casado I, Garcia-Rubira JC, Garcia-Prieto J, Sanz-Rosa D, Cuellas C, Hernandez-Antolin R, Albarran A, Fernandez-Vazquez F, de la Torre-Hernandez JM, Pocock S, Sanz G, Fuster V (2013) Effect of early metoprolol on infarct size in ST-segment-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: the effect of metoprolol in cardioprotection during an acute myocardial infarction (METOCARD-CNIC) trial. Circulation 128:1495–1503. https://doi.org/10.1161/CIRCULATIONAHA.113.003653
Pizarro G, Fernandez-Friera L, Fuster V, Fernandez-Jimenez R, Garcia-Ruiz JM, Garcia-Alvarez A, Mateos A, Barreiro MV, Escalera N, Rodriguez MD, de Miguel A, Garcia-Lunar I, Parra-Fuertes JJ, Sanchez-Gonzalez J, Pardillos L, Nieto B, Jimenez A, Abejon R, Bastante T, Martinez de Vega V, Cabrera JA, Lopez-Melgar B, Guzman G, Garcia-Prieto J, Mirelis JG, Zamorano JL, Albarran A, Goicolea J, Escaned J, Pocock S, Iniguez A, Fernandez-Ortiz A, Sanchez-Brunete V, Macaya C, Ibanez B (2014) Long-term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: results from the METOCARD-CNIC trial (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction). J Am Coll Cardiol 63:2356–2362. https://doi.org/10.1016/j.jacc.2014.03.014
Ibanez B, Fuster V, Macaya C, Sanchez-Brunete V, Pizarro G, Lopez-Romero P, Mateos A, Jimenez-Borreguero J, Fernandez-Ortiz A, Sanz G, Fernandez-Friera L, Corral E, Barreiro MV, Ruiz-Mateos B, Goicolea J, Hernandez-Antolin R, Acebal C, Garcia-Rubira JC, Albarran A, Zamorano JL, Casado I, Valenciano J, Fernandez-Vazquez F, de la Torre JM, Perez de Prado A, Iglesias-Vazquez JA, Martinez-Tenorio P, Iniguez A (2012) Study design for the “effect of METOprolol in CARDioproteCtioN during an acute myocardial InfarCtion” (METOCARD-CNIC): a randomized, controlled parallel-group, observer-blinded clinical trial of early pre-reperfusion metoprolol administration in ST-segment elevation myocardial infarction. Am Heart J 164(473–480):e475. https://doi.org/10.1016/j.ahj.2012.07.020
Valle-Caballero MJ, Fernandez-Jimenez R, Diaz-Munoz R, Mateos A, Rodriguez-Alvarez M, Iglesias-Vazquez JA, Saborido C, Navarro C, Dominguez ML, Gorjon L, Fontoira JC, Fuster V, Garcia-Rubira JC, Ibanez B (2016) QRS distortion in pre-reperfusion electrocardiogram is a bedside predictor of large myocardium at risk and infarct size (a METOCARD-CNIC trial substudy). Int J Cardiol 202:666–673. https://doi.org/10.1016/j.ijcard.2015.09.117
Weston P, Johanson P, Schwartz LM, Maynard C, Jennings RB, Wagner GS (2007) The value of both ST-segment and QRS complex changes during acute coronary occlusion for prediction of reperfusion-induced myocardial salvage in a canine model. J Electrocardiol 40:18–25. https://doi.org/10.1016/j.jelectrocard.2006.09.001
Ringborn M, Birnbaum Y, Nielsen SS, Kaltoft AK, Botker HE, Pahlm O, Wagner GS, Platonov PG, Terkelsen CJ (2014) Pre-hospital evaluation of electrocardiographic grade 3 ischemia predicts infarct progression and final infarct size in ST elevation myocardial infarction patients treated with primary percutaneous coronary intervention. J Electrocardiol 47:556–565. https://doi.org/10.1016/j.jelectrocard.2014.04.012
Cohen MV, Yang XM, Downey JM (1997) Attenuation of S-T segment elevation during repetitive coronary occlusions truly reflects the protection of ischemic preconditioning and is not an epiphenomenon. Basic Res Cardiol 92:426–434. https://doi.org/10.1007/BF00796217
Floyd JS, Maynard C, Weston P, Johanson P, Jennings RB, Wagner GS (2009) Effects of ischemic preconditioning and arterial collateral flow on ST-segment elevation and QRS complex prolongation in a canine model of acute coronary occlusion. J Electrocardiol 42:19–26. https://doi.org/10.1016/j.jelectrocard.2008.09.006
Deutsch E, Berger M, Kussmaul WG, Hirshfeld JW Jr, Herrmann HC, Laskey WK (1990) Adaptation to ischemia during percutaneous transluminal coronary angioplasty. Clinical, hemodynamic, and metabolic features. Circulation 82:2044–2051. https://doi.org/10.1161/01.cir.82.6.2044
Rentoukas I, Giannopoulos G, Kaoukis A, Kossyvakis C, Raisakis K, Driva M, Panagopoulou V, Tsarouchas K, Vavetsi S, Pyrgakis V, Deftereos S (2010) Cardioprotective role of remote ischemic periconditioning in primary percutaneous coronary intervention: enhancement by opioid action. JACC Cardiovasc Interv 3:49–55. https://doi.org/10.1016/j.jcin.2009.10.015
Botker HE, Kharbanda R, Schmidt MR, Bottcher M, Kaltoft AK, Terkelsen CJ, Munk K, Andersen NH, Hansen TM, Trautner S, Lassen JF, Christiansen EH, Krusell LR, Kristensen SD, Thuesen L, Nielsen SS, Rehling M, Sorensen HT, Redington AN, Nielsen TT (2010) Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial. Lancet 375:727–734. https://doi.org/10.1016/S0140-6736(09)62001-8
Dizon JM, Brener SJ, Maehara A, Witzenbichler B, Biviano A, Godlewski J, Parise H, Dambrink JH, Mehran R, Gibson CM, Stone GW (2014) Relationship between ST-segment resolution and anterior infarct size after primary percutaneous coronary intervention: analysis from the INFUSE-AMI trial. Eur Heart J Acute Cardiovasc Care 3:78–83. https://doi.org/10.1177/2048872613508658
Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Mitsuba N, Hata T, Nakama Y, Kisaka T, Kijima Y (2004) Impact of the magnitude of the initial ST-segment elevation on left ventricular function in patients with anterior acute myocardial infarction. Circ J 68:903–908. https://doi.org/10.1253/circj.68.903
Kleinbongard P (2020) Cardioprotection by early metoprolol-attenuation of ischemic vs. reperfusion injury? Basic Res Cardiol. https://doi.org/10.1007/s00395-020-0814-2
Martinez-Milla J, Raposeiras-Roubin S, Pascual-Figal DA, Ibanez B (2019) Role of beta-blockers in cardiovascular disease in 2019. Rev Esp Cardiol (Engl Ed) 72:844–852. https://doi.org/10.1016/j.rec.2019.04.014
Tucker WD, Sankar P, Theetha Kariyanna P (2021) Selective beta-1-blockers. StatPearls, Treasure Island
Van de Werf F, Janssens L, Brzostek T, Mortelmans L, Wackers FJ, Willems GM, Heidbuchel H, Lesaffre E, Scheys I, Collen D et al (1993) Short-term effects of early intravenous treatment with a beta-adrenergic blocking agent or a specific bradycardiac agent in patients with acute myocardial infarction receiving thrombolytic therapy. J Am Coll Cardiol 22:407–416. https://doi.org/10.1016/0735-1097(93)90044-2
Neil-Dwyer G, Bartlett J, McAinsh J, Cruickshank JM (1981) Beta-adrenoceptor blockers and the blood-brian barrier. Br J Clin Pharmacol 11:549–553. https://doi.org/10.1111/j.1365-2125.1981.tb01169.x
Basalay MV, Davidson SM, Gourine AV, Yellon DM (2018) Neural mechanisms in remote ischaemic conditioning in the heart and brain: mechanistic and translational aspects. Basic Res Cardiol 113:25. https://doi.org/10.1007/s00395-018-0684-z
Acknowledgements
Data of the present manuscript have been presented as part of R.D-M doctoral thesis. Simon Bartlett provided English editing.
Funding
Spanish Ministry of Science and Innovation (MICINN) RETOS2019-107332RB-I00 to B.I. Instituto de Salud Carlos III (ISCIII) PI19/01704 to R.F-J. European Research Council ERC-CoG 819775-MATRIX to B.I. European Union Horizon 2020 research and innovation programme under Marie Skłodowska-Curie grant agreement No 707642 to R.F-J. The METOCARD-CNIC trial was sponsored by the CNIC (Translational Grant 01-2009), the Spanish National Ministry of Health and Social Policy (EC10-042), and the Mutua Madrileña Foundation (AP8695-2011). This study forms part of a Master Research Agreement between the CNIC and Philips Healthcare. The CNIC is supported by the ISCIII, the MICINN, and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015–0505).
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Javier Sanchez-González is a Philips employee. All other authors state that they have no conflict of interests to declare.
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Díaz-Munoz, R., Valle-Caballero, M.J., Sanchez-Gonzalez, J. et al. Intravenous metoprolol during ongoing STEMI ameliorates markers of ischemic injury: a METOCARD-CNIC trial electrocardiographic study. Basic Res Cardiol 116, 45 (2021). https://doi.org/10.1007/s00395-021-00884-6
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DOI: https://doi.org/10.1007/s00395-021-00884-6