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Beta-Blocker Use in Older Patients With Stable Angina Undergoing Elective PCI
Study Questions:
What are the predictors, trends, and outcomes associated with beta-blocker use following percutaneous coronary intervention (PCI) in adults >65 years of age with stable angina and no history of myocardial infarction (MI) or significant left ventricular (LV) systolic dysfunction?
Methods:
This was a retrospective analysis of the National Cardiovascular Data Registry (NCDR) CathPCI registry and included patients with stable angina and LV ejection fraction (LVEF) >40% who underwent elective PCI between January 2005 and March 2013 (n = 755,215). Exclusion criteria were those patients with prior MI, coronary artery bypass grafting (CABG), systolic heart failure (HF), or contraindication to beta-blockers. Outcomes following discharge were restricted to patients >65 years of age using the Centers for Medicare and Medicaid Services fee-for-service data (n = 122,374). The primary outcome was all-cause mortality at 30 days and 3 years.
Results:
The majority of the study population (71.4%) was discharged on beta-blockers. The strongest predictors of beta-blocker prescriptions at discharge were hypertension (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.62-1.68), prior PCI (OR, 1.39; 95% CI, 1.37-1.42), prior HF (OR, 1.42; 95% CI, 1.38-1.46), higher LVEF (per 5 units when LVEF <60% OR, 1.11; 95% CI, 1.10-1.11), and presence of chronic lung disease (OR, 0.74; 95% CI, 0.73-0.76). There was a gradual increase in prescription of beta-blockers at discharge during the study period. The adjusted 30-day mortality rate for patients ≥65 years of age with CMS linkage data (16.3% of the study population) was similar for patients discharged with and without beta-blockers (hazard ratio [HR], 1.00; 95% CI, 0.96-1.03). There were no differences in the adjusted rates of hospitalization due to MI, revascularization, or stroke. There was an association between discharge with beta-blockers and rehospitalization for HF (HR, 1.70; 95% CI, 1.43-2.02). In 3-year follow-up, there were no differences in the adjusted rates of mortality, hospitalization related to MI, stroke, or revascularization between patients discharged with and without beta-blockers. There remained an association of increased rates of hospitalization related to HF and patients discharged on beta-blockers (HR, 1.18; 95% CI, 1.12-1.15).
Conclusions:
Prescriptions for beta-blockers at discharge following-elective PCI for patients with stable angina and no history of MI, CABG, or HF steadily increased between 2005 and 2013. In patients >65 years old, beta-blocker use at discharge was not associated with a reduction in mortality, revascularization, or rehospitalization related to MI, revascularization, or stroke at 30 days and 3 years.
Perspective:
Current guidelines recommend beta-blocker use in patients with prior MI and/or systolic HF. This study reports that beta-blocker use in patients >65 years of age with stable coronary artery disease undergoing elective PCI without prior history of MI or HF was associated with no difference in post-discharge mortality, revascularization, or rehospitalization due to MI or stroke at 30-day and 3-year follow-up. Due to this study being retrospective and observational, and its not being able to assess how treatment adherence may have influenced results, the findings are hypothesis-generating. That being said, these data suggest beta-blocker use in this patient population should be based on other coexisting cardiovascular conditions and underscores the need for prospective, randomized clinical trials to fully evaluate which patients with chronic ischemic heart disease without HF or prior MI would benefit from beta-blocker treatment.
Keywords: Acute Coronary Syndrome, Adrenergic beta-Antagonists, Angina, Stable, CathPCI Registry, Coronary Artery Bypass, Coronary Artery Disease, Geriatrics, Heart Failure, Systolic, Hypertension, Lung Diseases, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention, Stroke
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