Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction

S. B. Soumerai, T. J. McLaughlin, D. Spiegelman, E. Hertzmark, G. Thibault and L. Goldman
Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Mass 02215, USA.

OBJECTIVES: To study determinants and adverse outcomes (mortality and rehospitalization) of beta-blocker underuse in elderly patients with myocardial infarction; and whether the relative risks (RRs) of survival associated with beta-blocker use were comparable to those reported in the large randomized controlled trials (RCTs). SETTING: New Jersey Medicare population. DESIGN: Retrospective cohort design using linked Medicare and drug claims data from 1987 to 1992. PATIENTS: Statewide cohort of 5332 elderly 30-day acute myocardial infarction (AMI) survivors with prescription drug coverage, of whom 3737 were eligible for beta-blockers. MAIN OUTCOME MEASURES: beta-Blocker and calcium channel blocker use in the first 90 days after discharge and mortality rates and cardiac hospital readmissions over the 2-year period after discharge, controlling for sociodemographic and baseline risk variables. RESULTS: Only 21% of eligible patients received beta-blocker therapy; this rate remained unchanged from 1987 to 1991. Patients were almost 3 times more likely to receive a new prescription for a calcium channel blocker than for a new beta-blocker after their AMIs. Advanced age and calcium channel blocker use predicted underuse of beta-blockers. Controlling for other predictors of survival, the mortality rate among beta-blocker recipients was 43% less than that for nonrecipients (RR=0.57; 95% confidence interval [CI], 0.47-0.69). Effects on mortality were substantial in all age strata (65-74 years, 75-84 years, and > or = 85 years) and consistent with the results for elderly subgroups of 2 large RCTs. beta-Blocker recipients were rehospitalized 22% less often than nonrecipients (RR=0.78; 95% CI, 0.67-0.90). Use of a calcium channel blocker instead of a beta-blocker was associated with a doubled risk of death (RR= 1.98; 95% CI, 1.44-2.72), not because calcium channel blockers had a demonstrable adverse effect, but because they were substitutes for beta-blockers. CONCLUSIONS: beta-Blockers are underused in elderly AMI survivors, leading to measurable adverse outcomes. These data suggest that the survival benefits of beta-blockade after an AMI may extend to eligible patients older than 75 years, a group that has been excluded from RCTs.

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Arch Intern Med 1999;159:561-567.
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J. Am. Med. Inform. Assoc. 1999;6:99-103.
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J. Am. Med. Inform. Assoc. 1999;6:104-114.
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Weightman et al.
Anesth. Analg. 1999;88:286-286.
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Kendall et al.
JAMA 1999;281:131-133.
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Alexander et al.
J Am Coll Cardiol 1998;32:2023-2030.
ABSTRACT | FULL TEXT  

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Wang and Stafford
Arch Intern Med 1998;158:1901-1906.
ABSTRACT | FULL TEXT  

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Chassin et al.
JAMA 1998;280:1000-1005.
ABSTRACT | FULL TEXT  

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Gottlieb et al.
NEJM 1998;339:489-497.
ABSTRACT | FULL TEXT  

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Radford and Krumholz
NEJM 1998;339:551-553.
FULL TEXT  

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Krumholz et al.
JAMA 1998;280:623-629.
ABSTRACT | FULL TEXT  

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Donohoe
Arch Intern Med 1998;158:1596-1608.
ABSTRACT | FULL TEXT  

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Barron et al.
J Am Coll Cardiol 1998;32:360-367.
ABSTRACT | FULL TEXT  

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Barron et al.
Arch Intern Med 1998;158:449-453.
ABSTRACT | FULL TEXT  

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FULL TEXT  

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FULL TEXT  

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FULL TEXT  

UNDERUSE OF BETA BLOCKERS TIED TO WORSE OUTCOMES IN ELDERLY
JWatch General 1997;1997:1-1.
FULL TEXT  

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DeQuattro and Li
J CARDIOVASC PHARMACOL THER 1997;2:331-335.
ABSTRACT