Beta-Blockers and CAD: Think Treatment, Not Prevention
In a registry study, the agents did not reduce the risk for events in patients with — or at risk for — stable coronary artery disease.
Landmark trials of beta-blockers after myocardial infarction (MI) have led to the use of these agents in patients with stable coronary artery disease (CAD) and even in high-risk patients without CAD. To assess the effectiveness of beta-blockers for preventing coronary events in settings other than heart failure or post-acute MI, investigators used propensity score matching to compare outcomes with and without beta-blocker therapy in about half of more than 44,000 participants in the REACH registry who had prior MI, CAD without MI, or CAD risk factors only.
Median follow-up was 44 months. In both cohorts with CAD, the risk for cardiovascular death, MI, or stroke did not differ significantly between beta-blocker recipients and nonrecipients, whereas in the risk factor–only group, the risk was significantly higher (by 18%) in beta-blocker recipients than in nonrecipients. However, in patients with recent MI (1 year), beta-blockers were associated with a significant reduction in risk for major coronary events, including hospitalization for an atherothrombotic event or revascularization (odds ratio, 0.77; 95% confidence interval, 0.64–0.92).
Comment: This study is not strong enough to overturn the trial evidence, but it does remind us that we lack recent trials of beta-blocker therapy. Moreover, although the authors emphasize the lack of association between beta-blockers and a reduced risk for cardiovascular events, their results do confirm a benefit in patients with a recent MI. These findings are consistent with recent guidelines that strongly endorse beta-blockers only for heart failure and for short-term use after MI, but not for prevention in patients with chronic coronary disease.
To join a discussion with the lead author of this study, read his blog on CardioExchange, an online community hosted by the New England Journal of Medicine and Journal Watch and dedicated to improving cardiac patient care. Membership is free for medical professionals.
Published in Journal Watch Cardiology October 2, 2012
Bangalore S et al. for the REACH Registry Investigators. β-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA 2012 Oct 3; 308:1340.
- Medline abstract (Free)
To ensure that your Reader Remark is not formatted as one long paragraph, precede new paragraphs with either a blank line or an indentation.