Blanket prescribing of beta-blockers to all patients with CAD or at risk of CAD does not reduce cardiovascular risk

Beta-blocker therapy is not associated with a lower risk of death, nonfatal myocardial infarction (MI), and nonfatal stroke in patients with coronary artery disease (CAD) risk factors, known CAD without MI, or prior MI, according to a recent observational study.


Pragnesh Vachharajani, MD“…Trends are changing, and the evidence is compelling to use beta-blockers for the indications that are found to be beneficial in newer clinical studies.”
-Pragnesh Vachharajani, MBBS, family physician in Ahmedabad, India


These findings are especially significant for patients in India, since CAD mortalities present an average of 5 to 10 years earlier in Indian patients than in people from Western countries. CAD is the leading cause of morbidity and mortality worldwide, and Indians have the highest mortality due to CAD in the world (JAMA. 2007;297(3):286-294).

Beta-blocker therapy in India is prescribed primarily for post-MI patients and those at risk of coronary events, said Pragnesh Vachharajani, MBBS, a family physician in Ahmedabad, India, and a member of mdCurrent-India’s Editorial Advisory Board. “This study could definitely help us understand the role of beta-blockers in a better way,” he said.

The recent longitudinal study included 44,708 patients in the Reduction of Atherothrombosis for Continued Health (REACH) registry. The patients[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] were divided into 3 cohorts: CAD risk factors (18,653), known CAD without MI (12,012), or known prior MI (14,043). Of these patients, 21,860 were included in the primary analysis that used propensity score matching.

Key Point: Beta-blocker therapy was not associated with a lower risk of death, nonfatal myocardial infarction (MI), or nonfatal stroke in patients with coronary artery disease (CAD) risk factors, known CAD without MI, or prior MI. Although more studies are needed, these results indicate that beta-blockers may be most useful in patients with heart failure or recent MI rather than blanket prescribing of the agents to anyone with CAD or at risk of CAD.

The median follow-up of patients in this U.S.-based study was 44 months. Patients receiving beta-blocker therapy did not experience significantly different cardiovascular event rates vs those not receiving beta-blockers for the primary outcome. The primary outcome was a composite of cardiovascular death, nonfatal MI, or nonfatal stroke.

Although patients who had experienced a recent MI (1 year or less) did not have a lower rate of cardiovascular events if they were treated with beta-blockers, these patients did have a lower incidence (OR, 0.77 [95% CI, 0.64-0.92)] of the secondary outcome—the primary outcome plus hospitalization for a revascularization procedure or atherothrombotic events.

Weighing the risk:benefit ratio

While treatment with beta-blockers has been the standard of care for patients with CAD, particularly in those who have had an MI, the authors stated that the basis for this practice hinges primarily on heart failure trials and on older studies conducted in patients who had experienced an MI. Many of these post-MI studies were conducted prior to the advent of modern reperfusion or medical therapy, yet the studies have driven the practice to prescribe beta-blockers to patients with CAD and those at risk for CAD, the authors wrote.

However, the “…the long-term efficacy of these agents in patients treated with contemporary medical therapies is not known, even in patients with prior MI,” the authors stated. They added that “beta-blockers are not without adverse effects and their tolerability is not ideal.”

Future research

The results of the study are in keeping with current evidence-based guidelines from the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines, which recommend beta-blocker therapy for heart failure and for short-term use following an MI. There are no widely available evidence-based clinical guidelines that recommend beta-blockers for cardiovascular event prevention in patients with CAD or with CAD risk factors.

While this is an important study, more studies are needed before evidence-based clinical recommendations can be made. Further research, the authors stated, should focus on identifying subgroups that could benefit from beta-blocker therapy and the optimal duration of therapy.

“Beta-blockers are one of the most used drugs in studied conditions in India due to their long-standing usage and the confidence of doctors in using it,” Vachharajani said. “But trends are changing, and the evidence is compelling to use beta-blockers for the indications that are found to be beneficial in newer clinical studies.”

Sources: Bangalore S, Steg PG, Deedwania P, et al, for the REACH Registry Investigators. β-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA. 2012;38(13): 1340-1349.

Joshi P, Islam S, Pais P et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007;297(3):286-294.

Jessup M, Abraham WT, Casey DE, et al, for the 2009 Writing Group to Review New Evidence and Update the 2005 Guidelines for the Management of Patients with Chronic Heart Failure Writing on Behalf of the 2005 Heart Failure Writing Committee. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart and Lung Transplantation. Circulation. 2009;119:1977-2016

Access the original journal information here:
http://jama.jamanetwork.com/article.aspx?articleid=1367524
Journal publishers are independent from mdCurrent-India and may require a subscription or charge a fee to download the full article.

[/s2If]

Log in or register for free to continue reading
Register Now For Free Already Registered? Log In
This entry was posted in Cardiovascular, Pharmacology, Primary Care and tagged , , , , , , , , , , . Volume: .

Post a Comment

You must be logged in to post a comment.