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Beta-Blocker Use and CV Outcomes in Stable CAD
Quick Takes
- Using clinical, administrative, and laboratory databases, the initiation of beta-blocker therapy was found to be associated with a decrease in combined CV risk (composite of all-cause mortality, hospitalization for HF, or hospitalization for MI) among a population of patients 66-105 years old with angiographically documented CAD, LVEF ≥35%, and no history of HF.
- The risk reduction was relatively small (5-year absolute risk reduction, –1.8%; number needed to treat, 56 to prevent one major CV event at 5 years), and driven by a reduced risk of hospitalization for MI, with no differences observed in all-cause death or HF hospitalization.
Study Questions:
Is there an association between the initiation of beta-blockers and cardiovascular (CV) events among patients with stable coronary artery disease (CAD)?
Methods:
The CorHealth Ontario Cardiac Registry has prospectively collected clinical information on all patients undergoing an invasive cardiac procedure in Ontario, Canada, since 2008. This clinical registry was linked to administrative and laboratory data to identify all patients 66-105 years old who underwent elective coronary angiography in Ontario from 2009–2019 with a diagnosis of obstructive CAD (stenosis >50% left main or >70% in any major epicardial artery). Exclusion criteria included severe noncardiac comorbidities, heart failure (HF) or left ventricular ejection fraction (LVEF) <35%, myocardial infarction (MI) in the year prior to the angiogram, bypass surgery within 90 days after the angiogram, or having a beta-blocker prescription claim in the previous year. Beta-blocker use was defined as having at least one beta-blocker prescription claim in the 90 days preceding or after the index coronary angiogram. The main outcome measure was a composite of all-cause mortality, hospitalization for HF, or hospitalization for MI. Inverse probability of treatment weighting using the propensity score was utilized to account for confounding.
Results:
Of 294,966 patients who underwent elective coronary angiography for CAD evaluation, inclusion criteria were met in 28,039 (mean age 73.0 ± 5.6 years, 66.2% male); of these 12,695 (45.3%) had newly prescribed beta-blockers (bisoprolol in 66%, metoprolol in 29%, atenolol in 5%). The 5-year risk of the primary outcome was 14.3% in the beta-blocker group and 16.1% in the no beta-blocker group (absolute risk reduction, –1.8%; 95% confidence interval [CI], – 2.8 to –0.8; hazard ratio [HR], 0.92; 95% CI, 0.86-0.98; p = 0.006). The number needed to treat to prevent one major CV event at 5 years was 56 (95% CI, 36-120). Risk reduction was driven by a reduction in MI hospitalization (cause-specific HR, 0.87; 95% CI, 0.77-0.99; p = 0.031), whereas no differences were observed in all-cause death or HF hospitalization.
Conclusions:
In patients with angiographically documented stable CAD without HF or recent MI, beta-blocker initiation was associated with a small but significant reduction in CV events at 5 years.
Perspective:
Studies that demonstrated CV risk reduction associated with beta-blocker therapy among patients with acute MI became extrapolated to support their use in patients with stable ischemic heart disease until more recent studies suggested no benefit. The present study is interesting in that it required angiographic documentation of significant CAD, excluded patients with HF or reduced LVEF (with independent indications for beta-blocker therapy), and attempted to include only beta-blocker-naïve patients (thereby allowing the detection of any effects from the time of initial use). In addition to its observational design and the use of administrative databases, the study is limited by the inclusion of only patients >66 years old (for whom prescription claims data were available). With demonstration of a relatively small risk reduction and results contrary to other studies, prospective randomized trials still are needed to address whether and by what degree beta-blocker therapy might have a favorable effect among patients with stable CAD.
Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Adrenergic beta-Antagonists, Aged, 80 and over, Angiography, Atenolol, Bisoprolol, Coronary Artery Disease, Coronary Stenosis, Diagnostic Imaging, Geriatrics, Heart Failure, Metoprolol, Myocardial Infarction, Myocardial Ischemia, Outcome Assessment, Health Care, Prescription Drugs, Secondary Prevention, Stroke Volume, Ventricular Function, Left
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