Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction.

BACKGROUND Long-term administration of beta-adrenergic blockers to patients after myocardial infarction improves survival. However, physicians are reluctant to administer beta-blockers to many patients, such as older patients and those with chronic pulmonary disease, left ventricular dysfunction, or non-Q-wave myocardial infarction. METHODS The medical records of 201,752 patients with myocardial infarction were abstracted by the Cooperative Cardiovascular Project, which was sponsored by the Health Care Financing Administration. Using a Cox proportional-hazards model that accounted for multiple factors that might influence survival, we compared mortality among patients treated with beta-blockers with mortality among untreated patients during the two years after myocardial infarction. RESULTS A total of 34 percent of the patients received beta-blockers. The percentage was lower among the very elderly, blacks, and patients with the lowest ejection fractions, heart failure, chronic obstructive pulmonary disease, elevated serum creatinine concentrations, or type 1 diabetes mellitus. Nevertheless, mortality was lower in every subgroup of patients treated with beta-blockade than in untreated patients. In patients with myocardial infarction and no other complications, treatment with beta-blockers was associated with a 40 percent reduction in mortality. Mortality was also reduced by 40 percent in patients with non-Q-wave infarction and those with chronic obstructive pulmonary disease. Blacks, patients 80 years old or older, and those with a left ventricular ejection fraction below 20 percent, serum creatinine concentration greater than 1.4 mg per deciliter (124 micromol per liter), or diabetes mellitus had a lower percentage reduction in mortality. Given, however, the higher mortality rates in these subgroups, the absolute reduction in mortality was similar to or greater than that among patients with no specific risk factors. CONCLUSIONS After myocardial infarction, patients with conditions that are often considered contraindications to beta-blockade (such as heart failure, pulmonary disease, and older age) and those with nontransmural infarction benefit from beta-blocker therapy.

[1]  J. Kjekshus,et al.  Timolol Treatment After Myocardial Infarction in Diabetic Patients , 1983, Diabetes Care.

[2]  L. Haywood.  Coronary heart disease mortality/morbidity and risk in blacks. I: Clinical manifestations and diagnostic criteria: the experience with the Beta Blocker Heart Attack Trial. , 1984, American heart journal.

[3]  L. Wilkins.  A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). CIBIS Investigators and Committees. , 1994, Circulation.

[4]  R. Becker.  Beta‐adrenergic blockade following thrombolytic therapy: Is it helpful or harmful? , 1994, Clinical cardiology.

[5]  S. Viskin,et al.  Treatment with beta-adrenergic blocking agents after myocardial infarction: from randomized trials to clinical practice. , 1995, Journal of the American College of Cardiology.

[6]  T. Killip,et al.  Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. , 1967, The American journal of cardiology.

[7]  K. Swedberg,et al.  EFFECT ON MORTALITY OF METOPROLOL IN ACUTE MYOCARDIAL INFARCTION A Double-blind Randomised Trial , 1981, The Lancet.

[8]  K. Swedberg,et al.  Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy , 1993, The Lancet.

[9]  A. Maggioni,et al.  Influence of diabetes on mortality in acute myocardial infarction: data from the GISSI-2 study. , 1993, Journal of the American College of Cardiology.

[10]  H. Krumholz,et al.  Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project. , 1998, JAMA.

[11]  D. Renlund,et al.  Beta-blockade with bucindolol in heart failure caused by ischemic versus idiopathic dilated cardiomyopathy. , 1991, Circulation.

[12]  J. Anderson.  Medical Therapy for Elderly Patients Who Have Had Myocardial Infarction: Too Little to the Late in Life? , 1996, Annals of Internal Medicine.

[13]  Richard P. Lewis,et al.  ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). , 1996, Journal of the American College of Cardiology.

[14]  D J Reda,et al.  Single-Drug Therapy for Hypertension in Men -- A Comparison of Six Antihypertensive Agents with Placebo , 1993 .

[15]  J. Cohn,et al.  The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. , 1996, The New England journal of medicine.

[16]  R. Marfella,et al.  Metabolic and Cardiovascular Effects of Carvedilol and Atenolol in Non-Insulin-Dependent Diabetes Mellitus and Hypertension , 1997, Annals of Internal Medicine.

[17]  W. Rogers,et al.  Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) II-B Study. , 1991, Circulation.

[18]  L. Rydén,et al.  Effects of metoprolol on mortality and late infarction in diabetics with suspected acute myocardial infarction. Retrospective data from two large studies. , 1989, European heart journal.

[19]  S. Anderson,et al.  Characteristics of bronchial hyperresponsiveness in chronic obstructive pulmonary disease and in asthma. , 1991, The American review of respiratory disease.

[20]  E. Gilpin,et al.  Diabetic patients and beta-blockers after acute myocardial infarction. , 1990, European heart journal.

[21]  W. Knaus,et al.  APACHE II: a severity of disease classification system. , 1985 .

[22]  R. N. Stiles,et al.  Racial Differences in β‐Adrenoceptor-Mediated Responsiveness , 1995 .

[23]  M. Gold,et al.  Esmolol and ventilatory function in cardiac patients with COPD. , 1991, Chest.

[24]  J. Kjekshus,et al.  Timolol‐related Reduction in Mortality and Reinfarction in Patients Ages 65‐75 Years Surviving Acute Myocardial Infarction , 1982, Circulation.

[25]  D. Brand,et al.  Cardiologists' practices compared with practice guidelines: use of beta-blockade after acute myocardial infarction. , 1995, Journal of the American College of Cardiology.

[26]  R. Byington,et al.  Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. , 1986, Circulation.

[27]  W. Aronow.  Prevalence of Use of Beta Blockers and of Calcium Channel Blockers in Older Patients with Prior Myocardial Infarction at the Time of Admission to a Nursing Home , 1996, Journal of the American Geriatrics Society.

[28]  G. Mensah,et al.  Use of β ‐ Adrenergic Receptor Blockers in Blacks , 1996 .