Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction
Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction
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DOI：
10.1001/jama.277.2.115
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发表时间：
1997-01-08
影响因子：
120.7
通讯作者：
Goldman, L
中科院分区：
文献类型：
--
作者：
Soumeral, SB;McLaughlin, TJ;Goldman, L
目的-研究老年心肌梗死患者β受体阻滞剂使用不足的决定因素和不良结局（死亡率和再住院率）;以及与β受体阻滞剂使用相关的生存相对风险（RR）是否与大型随机对照试验（RCT）中报告的结果相当。新泽西医保人口。设计。-回顾性队列设计使用1987年至1992年的相关医疗保险和药物索赔数据。在全州范围内，有处方药覆盖的5332名30天急性心肌梗死（AMI）幸存者，其中3737名有资格接受β受体阻滞剂治疗。β-受体阻滞剂和钙通道阻滞剂的使用在出院后的前90天和死亡率和心脏病医院再入院超过出院后的2年期间，控制社会人口统计学和基线风险变量。只有21%的合格患者接受了β受体阻滞剂治疗;这一比例从1987年到1991年保持不变。患者在AMI后接受新的钙通道阻滞剂处方的可能性几乎是接受新的β受体阻滞剂处方的3倍。高龄和钙通道阻滞剂的使用预示着β受体阻滞剂的使用不足。在控制其他生存预测因素后，β受体阻滞剂接受者的死亡率比非接受者低43%（RR=0.57; 95%可信区间[CI]，0.47-0.69）。所有年龄层（65-74岁、75-84岁和≥ 85岁）对死亡率的影响都很大，与2项大型RCT的老年亚组结果一致，β受体阻滞剂接受者的再住院率比非接受者低22%（RR=0.78; 95%CI，0.67-0.90）。使用钙通道阻滞剂而不是β受体阻滞剂与死亡风险加倍相关（RR=1.98; 95% CI，1.44-2.72），不是因为钙通道阻滞剂有明显的不良反应，而是因为它们是β受体阻滞剂的替代品。β受体阻滞剂在老年AMI幸存者中使用不足，导致可测量的不良结局。这些数据表明，AMI后β受体阻滞剂的生存益处可能延伸到年龄超过75岁的合格患者，这一组已被排除在RCT之外。
Objectives-To study determinants and adverse outcomes (mortality and rehospitalization) of beta-blocker underuse in elderly patients with myocardial infarction; and whether the relative risks (RRs) of survival associated with beta-blocker use were comparable to those reported in the large randomized controlled trials (RCTs).Setting.-New Jersey Medicare population.Design.-Retrospective cohort design using linked Medicare and drug claims data from 1987 to 1992.Patients.-Statewide cohort of 5332 elderly 30-day acute myocardial infarction (AMI) survivors with prescription drug coverage, of whom 3737 were eligible for beta-blockers.Main Outcome Measures.-beta-Blocker and calcium channel blocker use in the first 90 days after discharge and mortality rates and cardiac hospital readmissions over the 2-year period after discharge, controlling for sociodemographic and baseline risk variables.Results.-Only 21% of eligible patients received beta-blocker therapy; this rate remained unchanged from 1987 to 1991. Patients were almost 3 times more likely to receive a new prescription for a calcium channel blocker than for a new beta-blocker after their AMIs. Advanced age and calcium channel blocker use predicted underuse of beta-blockers. Controlling for other predictors of survival, the mortality rate among beta-blocker recipients was 43% less than that for nonrecipients (RR=0.57; 95% confidence interval [CI], 0.47-0.69). Effects on mortality were substantial in all age strata (65-74 years, 75-84 years, and greater than or equal to 85 years) and consistent with the results for elderly subgroups of 2 large RCTs, beta-Blocker recipients were rehospitalized 22% less often than nonrecipients (RR=0.78; 95% CI, 0.67-0.90). Use of a calcium channel blocker instead of a beta-blocker was associated with a doubled risk of death (RR=1.98; 95% CI, 1.44-2.72), not because calcium channel blockers had a demonstrable adverse effect, but because they were substitutes for beta-blockers.Conclusions.-beta-Blockers are underused in elderly AMI survivors, leading to measurable adverse outcomes. These data suggest that the survival benefits of beta-blockade after an AMI may extend to eligible patients older than 75 years, a group that has been excluded from RCTs.