Abstract
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). New Jersey Medicare population. Retrospective cohort design using linked Medicare and drug claims data from 1987 to 1992. Statewide cohort of 5332 elderly 30-day acute myocardial infarction (AMI) survivors with prescription drug coverage, of whom 3737 were eligible for beta-blockers. 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. 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. 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.
Highlights
Objectives.\p=m-\Tostudy determinants and adverse outcomes of \g=b\-blockerunderuse in elderly patients with myocardial infarction; and whether the relative risks (RRs) of survival associated with \g=b\-blockeruse were comparable to those reported in the large randomized controlled trials (RCTs)
Advanced age and calcium channel blocker use predicted underuse of \g=b\-blockers.Controlling for other predictors of survival, the mortality rate among \g=b\-blockerrecipients was 43% less than that for nonrecipients (RR=0.57; 95% confidence interval [confidence intervals (CIs)], 0.47-0.69)
Effects on mortality were substantial in all age strata (65-74 years, 75-84 years, and \m=ge\85years) and consistent with the results for elderly subgroups of 2 large RCTs. \g=b\-Blockerrecipients were rehospitalized 22% less often than nonrecipients (RR=0.78; 95% CI, 0.67-0.90)
Summary
Objectives.\p=m-\Tostudy determinants and adverse outcomes (mortality and rehospitalization) of \g=b\-blockerunderuse in elderly patients with myocardial infarction; and whether the relative risks (RRs) of survival associated with \g=b\-blockeruse were comparable to those reported in the large randomized controlled trials (RCTs). SS-BLOCKER prophylaxis after acute myocardial infarction (AMD is one of the most scientifically substantiated, cost-effective preventive medical ser¬ vices.[1] Multiple randomized controlled trials (RCTs), involving over 20 000 pa¬ tients, have shown that ß-blocker use following AMI decreases cardiovascu¬ lar mortality and reinfarctions and in¬ creases the chances of survival by 20%. We sought to answer the following specific questions: (1) What proportion of eligible elderly AMI pa¬ tients receive ß-blocker prophylaxis af¬ ter AMI? (2) Controlling for differences in risk status, are patient characteris¬ tics (age, sex, race, socioeconomic sta¬ tus [SES]) and use of alternative medi¬ cations (eg, calcium channel blockers) associated with receipt of ß-blockers in eligible patients? (3) Is the nonuse of ß-blockers among eligible patients as¬ sociated with increased mortality and rehospitalization for cardiovascular ill¬ ness following AMI, controlling for po¬ tentially confounding patient variables? (4) Are the relative mortality rates as¬ sociated with ß-blocker use obtained in this observational study comparable to those reported for elderly subgroups of large RCTs?
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