NEW YORK, NY — Beta-blocker use after elective PCI does not improve short- or long-term cardiovascular outcomes, including survival, for older patients with stable angina and no history of systolic MI or heart failure (HF), a registry analysis indicates[1].
The observational study of 755,215 patients, aged >65 years, in the US NCDR CathPCI registry showed no differences between patients with and without beta-blockers at discharge in adjusted 30-day rates of mortality (hazard ratio [HR] 0.86, P=0.08), MI (HR 1.13, P=0.24), stroke (HR 1.07, P=0.72), or revascularization (HR 0.94, P=0.06).
At 3 years, adjusted rates were also similar for mortality (HR 1.00, P=0.84), MI (HR 1.00, P=0.91), stroke (HR 1.08, P=0.14), and revascularization (HR 0.97, P=0.10).
Beta-blockers, however, were associated with a higher incidence of HF readmissions at both 30 days (adjusted HR 1.70, P<0.01) and 3 years (adjusted HR 1.18, P<0.01).
The investigators, led by Dr Apurva Motivala (Columbia University, NY), note that the hypothesis-generating findings suggest beta-blocker use in this population "should be customized based on other concomitant cardiovascular conditions and completeness of revascularization."
Regarding the higher HF readmissions among patients using beta-blockers, the mechanism and potential for harm is unclear, although the likely inclusion of patients with prior HF and LVEF >40% and residual confounders may help explain this, Motivala et al write.
The research is published in the August 22, 2016 issue of JACC: Cardiovascular Interventions.
The study reinforces the concept that for those with stable ischemic heart disease (SIHD) without HF, beta-blockers should be used selectively, Dr Christopher Granger (Duke University School of Medicine, Durham, NC), who was not involved in the study, commented to heartwire from Medscape.
"Beta-blockers may be important for some patients who either have some ongoing angina or hypertension, but for many patients they're not a priority, and in fact we should concentrate on the treatments that have proved to be important, such as statins and antiplatelet therapy," he added.
Beta-blockers are first-line agents in US and European guidelines for controlling angina and relieving myocardial ischemia in patients with SIHD. They carry a class I recommendation in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for use in CAD patients with MI and in systolic HF based on numerous trials dating back to the 1980s.
In an accompanying editorial[2], Dr Anthony Nappi (Albany Medical College, NY) and Dr William E Boden (Clinical Trials Network, VA New England Healthcare System, Boston, MA) also call for a more cautious and selective use of beta-blockers and write that the study "raises questions about the continued role of beta-blocker usage in patients with CAD undergoing PCI."
They note that for years, clinicians have extrapolated the evidence of beta-blocker benefit from these older post-MI trials—conducted in an earlier era before the advent of PCI and optimized medical therapy—and applied it to all patients with CAD.
"It seems increasingly difficult to justify the continued class IA/IB clinical practice guideline recommendations for beta-blocker use by professional cardiovascular societies where the evidence of clinical benefit in patients without prior MI or heart failure/LV dysfunction is largely lacking," they write.
Motivala reports no relevant financial relationships. Disclosures for the coauthors are listed in the article. Nappi and Boden reported no relevant financial relationships.
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Heartwire from Medscape © 2016 Medscape, LLC
Cite this: Post-PCI Beta-Blockers Offer No Benefit in Some Seniors: NCDR Analysis - Medscape - Aug 25, 2016.
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