National Use and Effectiveness of β-Blockers for the Treatment of Elderly Patients After Acute Myocardial Infarction

Abstract

Context.-Despite the importance of ␤-blockers for secondary prevention after acute myocardial infarction (AMI), several studies have suggested that they are substantially underutilized, particularly in older patients.Objectives.-To describe the contemporary national pattern of ␤-blocker prescription at hospital discharge among patients aged 65 years or older with an AMI, to identify the most important predictors of the prescribed use of ␤-blockers at discharge, and to determine the independent association between ␤-blockers at discharge and mortality in clinical practice.Design.-Retrospective cohort study using data created from medical charts and administrative files.Setting.-Acute care nongovernmental hospitals in the United States.Patients.-National cohort of 115 015 eligible patients aged 65 years or older who survived hospitalization with a confirmed AMI in 1994 or 1995.Main Outcome Measures.-␤-Blocker as a discharge medication and mortality in the year after discharge.Results.-Among the 45 308 patients without contraindications to ␤-blockers, 22 665 (50.0%) had a ␤-blocker as a discharge medication. There was significant variation by state, ranging from 30.3% to 77.1%. Of the 36 795 patients who were not receiving ␤-blocker therapy on admission, 16 006 (43.5%) had therapy initiated on or before discharge. Demographic and clinical variables explained relatively little of the variation in the initiation of ␤-blocker therapy. The prescribed use of calcium channel blockers at discharge had a strong negative association with the use of ␤blockers (odds ratio [OR] of ␤-blocker use, 0.25; 95% confidence interval [CI], 0.24-0.26). The New England region had significantly higher use of ␤-blocker therapy than the rest of the country. Compared with cardiologists, internists had similar rates (OR, 0.94; 95% CI, 0.90-1.00) and general and family practice physicians had lower rates (OR, 0.78; 95% CI, 0.73-0.83). After adjusting for potential confounders, ␤-blockers were associated with a 14% lower risk of mortality at 1 year after discharge. The association with lower mortality was present in subgroups stratified by age, sex, and left ventricular ejection fraction.Conclusions.-Many ideal patients for ␤-blocker therapy are not prescribed these drugs at discharge following AMI. The clinical and demographic characteristics of the patients do not explain much of the variation in the treatment pattern. Geographic factors and physician specialty are independently associated with the decision to use ␤-blockers. Elderly patients who are prescribed ␤-blockers at discharge have a better survival rate, consistent with the findings of randomized controlled trials of younger and lower-risk populations.

Acute Coronary Syndrome in the Elderly

“…29 There is some controversy regarding the use of intravenous (IV) β-blockers in acute STEMI in the elderly with some trials concluding that there is a significant reduction in mortality in the elderly subgroup compared to younger patients. 30 The COMMIT trial concluded that IV metoprolol did not result in a reduction in all-cause mortality or the composite end point of death, MI, or cardiac arrest in the elderly, and there was a trend towards increased rates of congestive heart failure (CHF) and cardiogenic shock.…”

“…Most of these trials have excluded patients greater than 75 years of age, but multiple observational studies provide strong evidence that long-term β-blockade after ACS improves outcomes in patients up to 90 years of age. 29 …”

Medical treatment of patients with stable angina pectoris referred for coronary angiography: Failure of treatment or failure to treat

“…[11][12][13][14][15][16][17] Use of beta blockers is influenced by many factors, such as patient age, geographical location, visits to cardiologist or internist versus family or general practitioner, race, and health care system characteristics. [11][12][13][14][15][16][17][18][19][20] Temporal variability in the use of beta blockers has been documented. 11,17,19 Calcium-channel blockers and/or long-acting nitrates can be added to beta blockers or replace them if beta blockade is contraindicated or poorly tolerated.…”

Changes in secondary pharmacological prevention of acute coronary syndromes and stroke after hospital discharge: a 6-month follow-up study of German primary care patients

“…As outlined in these therapeutic guidelines, antiplatelet, antihypertensive, and lipid-lowering therapies are known to significantly reduce the risk of recurrence of macrovascular diseases, such as coronary and cerebrovascular diseases. Contrary to this, national and international studies have shown that these guidelines are not yet fully implemented in primary and secondary prevention with respect to platelet aggregation inhibitors, angiotensin-converting enzyme (ACE) inhibitors, betablockers, and statins (EUROASPIRE I and II Group 2001;Krumholz et al 1998;Welterman et al 1997) in the prevention of ACS. However, long-term secondary stroke prevention in Germany has revealed better findings, especially with regard to antithrombotic medications (Hamann et al 2003).…”