Caution: Harsh language & Unscientific truths
It is a pattern out there, rolled out periodically in cardiac- pharma literature . It happened for Digoxin. They have been trying to do this to beta blockers for quite some time. They successfully ditched beta blockers in systemic hypertension with synthesized evidence. Mind you, BBs are the only drug that received a Nobel Prize for its invention, and its role in post-MI protection is well established.
The script is well written. Trying to ring a death knell for cheap and established medical therapeutic norms, citing lack of evidence. It is done based on some non-sensical study designs called Non-Inferiority Trials. (Tannock I, Buyse M, De Backer M et al.The tyranny of non-inferiority trials The Lancet Oncology, 25, e520-e525 Now, powerful cartels want to get rid of BBs in post-MI ecosystem. REBOOT, REDUCE-AMI, ABYSS all were done with fixed ideas. Of course, ABYSS didn’t follow their agenda. Now, a the latest trial has come out with a magical name SMART – DECISION.
Read this paper https://www.nejm.org/doi/full/10.1056/NEJMoa2601005
One famous statistician said, non-inferiority study concept is foundationally flawed. Hence, it is generally not worth reviewing them, as most conclusions are deemed to be wrong and not scientifically consumable. Still, looking beyond the trial design, three important flaws are obvious in SMART-DECISION’ trial , which argues for beta-blocker discontinuation after MI.
The study population is highly selected (median 4.7 years 98% revascularized; median LVEF 59%). The study advocated discontinuation among long-term accrued beneficiaries of BBs rather than typical 6–36-month post-ACS patients. Physician-driven HF hospitalization amplifies open-label bias. A wide non-inferiority margin (HR upper CI <1.4) plus low events (132 total) leave it underpowered, unable to exclude modest 15–25% harm (7.2% vs 9.0%).
Final message
In science, we need to be right first … being polite is optional.
When big science tries to corrupt our minds, what should we do? Let us continue with our conscience and follow the instinct and work for the welfare of our patients. We know the healing power of BBs. Let us be cautious and alert. Never allow wayward science to intrude upon our minds to take STUPID DECISIONS and defame the OMT in CAD.
Postamble
A newchallenge to take on
Fact : There is no published RCT that proves diuretics improve mortality and survival in heart failure.
Action requested : Let all evidence-based cardiologists withhold injections of Furosemide or Torsemide when they encounter their next patient with acute heart failure and pulmonary edema.
Dr.S.Venkatesan MD 