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Support for de-prescribing beta-blockers beyond 3 years post-MI in older adults


July 18, 2019

By Megan Brooks

NEW YORK (Reuters Health) - Beta-blocker use beyond 3 years after myocardial infarction is common in the elderly but it doesn't yield improved long-term outcomes, according to a new analysis.

Beta-blocker therapy is recommended for at least 3 years after MI but the benefit beyond 3 years has not been clearly demonstrated, say Dr. Jay Shavadia from Duke Clinical Research Institute in Durham, North Carolina and colleagues.

To investigate, they analyzed data from the CRUSADE registry on 6,893 MI patients aged 65 and older who were discharged on beta-blocker therapy and alive 3 years later without a recurrent MI. Nearly three quarters of the patients (72%) were still on a beta-blocker at 3 years; 43% of them were taking at least 50% of the recommended target beta-blocker dose.

However, beta-blocker use was not associated with a significant difference in the cardiovascular composite of all-cause mortality, hospitalization for recurrent MI, ischemic stroke, or heart failure over the subsequent 5 years (52.4% vs 55.4%, adjusted hazard ratio, 0.95; 95% CI, 0.88 to 1.03; P=0.23).

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Commenting by email to Reuters Health on why it was important to do this comparative effectiveness analysis, Dr. Shavadia said, "MI care pre/in/post hospital has evolved substantially both in terms of efficiency of revascularization and pharmacotherapies. Therefore, in patients who are most susceptible to the adverse effects of beta-blocker therapy, their long-term role (beyond the time they were evaluated in most clinical trials) is unknown. Also, older post MI patients have a high competing risk of a non CV death which beta-blockers do not mitigate. We therefore sought to evaluate whether beta-blocker use beyond years post MI in older patients associates with clinical outcomes."

"Our patient population is highly selected to include older 3 year MI survivors. In these patients, our result suggest that if clinicians are thinking about deprescribing post-MI therapies for whatever reason, beta-blocker de-prescription could be considered beyond 3 years if patients haven't had another ischemic event," said Dr. Shavadia.

He cautioned, however, "as this was an observational analysis, clinicians should carefully consider these results in application to their day-to-day clinical practice. What I think it will change, is the drive for a randomized deprescription trial."

Dr. Jonathan Halperin, cardiologist at The Mount Sinai Hospital in New York City who reviewed the study for Reuters Health commented by email, "I don't think this will impact practice, as the results align with current practice guidelines and derive from registry data that don't sufficiently account for clinical factors that could have influenced prescriptive practice during the observation period."

SOURCE: http://bit.ly/2SpNivh

Circ Cardiovasc Qual Outcomes 2019.

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