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Journal Club 20 February 2013

Paper

Beta-Blocker Use and Clinical Outcomes in Stable Outpatients With and Without Coronary Artery Disease

Presenter

SH

Summary

Context

Beta-Blockers remain the standard of care after a myocardial infarction (MI).
However, the benefit of beta-blocker use in patients with coronary artery disease (CAD)
but no history of MI, those with a remote history of MI, and those with only risk factors
for CAD is unclear.

Objective

To assess the association of beta-blocker use with cardiovascular events in
stable patients with a prior history of MI, in those with CAD but no history of MI, and
in those with only risk factors for CAD.

Design, Setting, and Patients

Longitudinal, observational study of patients in the
Reduction of Atherothrombosis for Continued Health (REACH) registry who were divided
into 3 cohorts: known prior MI (n=14 043), known CAD without MI (n=12 012),
or those with CAD risk factors only (n=18 653). Propensity score matching was used
for the primary analyses. The last follow-up data collection was April 2009.

Main Outcome Measures

The primary outcome was a composite of cardiovascular
death, nonfatal MI, or nonfatal stroke. The secondary outcome was the primary
outcome plus hospitalization for atherothrombotic events or a revascularization procedure.

Results

Among the 44 708 patients, 21 860 were included in the propensity score–
matched analysis. With a median follow-up of 44 months (interquartile range, 35-45
months), event rates were not significantly different in patients with beta-blocker use compared
with those without beta-blocker use for any of the outcomes tested, even in the prior
MI cohort (489 [16.93%] vs 532 [18.60%], respectively; hazard ratio [HR], 0.90 [95%
CI, 0.79-1.03]; P=.14). In the CAD without MI cohort, the associated event rates were
not significantly different in those with beta-blocker use for the primary outcome (391
[12.94%]) vs without beta-blocker use (405 [13.55%]) (HR, 0.92[95%CI, 0.79-1.08]; P=.31),
with higher rates for the secondary outcome (1101 [30.59%] vs 1002 [27.84%]; odds
ratio [OR], 1.14 [95% CI, 1.03-1.27]; P=.01) and for the tertiary outcome of hospitalization
(870 [24.17%] vs 773 [21.48%]; OR, 1.17 [95% CI, 1.04-1.30]; P=.01). In the
cohort with CAD risk factors only, the event rates were higher for the primary outcome
with beta-blocker use (467 [14.22%]) vs without beta-blocker use (403 [12.11%]) (HR, 1.18
[95% CI, 1.02-1.36]; P=.02), for the secondary outcome (870 [22.01%] vs 797 [20.17%];
OR, 1.12 [95% CI, 1.00-1.24]; P=.04) but not for the tertiary outcomes of MI (89 [2.82%]
vs 68 [2.00%]; HR, 1.36 [95% CI, 0.97-1.90]; P=.08) and stroke (210 [6.55%] vs 168
[5.12%]; HR, 1.22 [95% CI, 0.99-1.52]; P=.06). However, in those with recent MI (1
year), beta-blocker use was associated with a lower incidence of the secondary outcome
(OR, 0.77 [95% CI, 0.64-0.92]).

Conclusion

In this observational study of patients with either CAD risk factors only,
known prior MI, or known CAD without MI, the use of beta-blockers was not associated
with a lower risk of composite cardiovascular events

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