Apurva Motivala (Division of Cardiology, Columbia University, New York, USA) and others report that patients who are prescribed beta-blockers after undergoing elective percutaneous coronary intervention (PCI) for stable angina, without prior myocardial infarction, do not have significantly reduced morbidity or mortality at 30 days or at three years compared with patients who were not prescribed beta-blockers. They add these results suggest that the use of beta-blockers in this population should be based on other concomitant cardiovascular conditions and completeness of revascularisation.
Writing in JACC: Cardiovascular Interventions, the authors comment that the benefits of beta-blockers for improving cardiovascular outcomes in patients with myocardial infarction and/or systolic heart failure are “well established”. They note that the drugs are also known to be beneficial for patients with stable angina not undergoing revascularisation but add: “Whether beta-blockers reduce morbidity and mortality in patients with stable angina without prior myocardial infarction and/or systolic heart failure undergoing revascularisation with PCI remains unclear.”
Therefore, the aim of the present study was to compare outcomes of patients with stable angina without prior myocardial infarction/systolic heart failure undergoing elective PCI who were prescribed beta-blockers after the procedure with those of patients not prescribed beta-blockers. The authors also sought to “assess predictors and temporal trends affecting prescription of beta-blockers at discharge in this population”.
Using data from the National Cardiovascular Data Registry (NCDR) CathPCI registry, Motivala et al identified 755, 215 (of 4,523,488 overall) stable angina patients (aged ≥65 years) without a prior history of myocardial infarction and/or systolic heart failure who underwent elective PCI. Of these, the majority (71.4%) were prescribed beta-blockers at discharge. “Patients discharged on beta-blockers were younger, more likely to be female and more likely to have history of hypertension, diabetes, dyslipidaemia, smoking, dialysis, prior PCI, and prior and current heart failure,” the authors comment. They add that the strongest predictors of beta-blockers at discharge were hypertension, prior PCI, lack of chronic lung disease, higher left ventricular ejection fraction values, and prior congestive heart failure. Furthermore, between 2005 and 2013, there was a gradual increase in prescription of beta-blockers at index discharge.
Outcome data were available for 122,734 patients. These data showed that at both 30 days at three years, there were no significant differences in the rate of all-cause mortality (the primary endpoint) between patients who were prescribed beta-blockers and those who were not. There were also no significant differences, at either time point, in the rate of hospitalisation related to myocardial infarction, stroke, or revascularisation. However, again at both time points, beta-blocker prescription at discharge was associated with higher rates of hospitalisation related to heart failure.
According to Motivala et al, the lack of improvement in outcomes observed with beta-blockers in this study seems “counter-intuitive” and may be attributable to “multiple reasons”. For example beta-blockers are “poor at achieving optimal control of essential hypertension”. However, they note that the patients prescribed beta-blockers in the study had a higher prevalence of atherosclerotic events “and despite that, there were no significant increases in mortality and morbidity observed”. “There is a probability that these patients may have had higher events rate if they were not prescribed beta-blockers. It is possible that beta-blockers provide beneficial effects, but the magnitude may be less compared to following an acute coronary syndrome,” the authors write.
Concluding their findings, Motivala et al note that their “hypothesis-generating” findings “suggest that the use of beta-blockers in this population should be customised based on other concomitant cardiovascular conditions and completeness of revascularisation”.
Motivala told Cardiovascular News: “I would still prescribe beta blockers post revascularisation for stable angina patients if they are incompletely revascularised or have other compelling indications for their prescription. More importantly, I would now have a much lower threshold to discontinue beta-blockers in similar patients who are unable to tolerate them.”