β-Blocker therapy in acute myocardial infarction: Evidence for underutilization in the elderly

doi:10.1016/0002-9343(92)90192-E

The American Journal of Medicine

Volume 93, Issue 6, December 1992, Pages 605-610

https://doi.org/10.1016/0002-9343(92)90192-E Get rights and content

Abstract

purpose: To assess the impact of patient age on the use of β-blocker therapy in the management of acute myocardial infarction.

patients and methods: The population studied consisted of 4,762 patients hospitalized with validated acute myocardial infarction in 16 hospitals in the Worcester, Massachusetts, Standard Metropolitan Statistical Area during the years 1975, 1978, 1981, 1984, 1986, and 1988. Logistic regression analysis was employed to control for relevant demographic and clinical variables in evaluating the independent effect of patient age as a determinant of receipt of β-blocker therapy during the hospitalization.

results: A consistent trend toward reduced use of β-blocker therapy in older patients was demonstrated. After adjustment for demographic and clinical variables (gender; prior history of angina, hypertension, or diabetes mellitus; myocardial infarction characteristics; complications including congestive heart failure and shock; and use of digoxin and diuretics), odds ratios for receipt of β-blocker therapy relative to patients less than 55 years of age were 0.61 for those 55 to 64; 0.52 for those 65 to 74; 0.36 for those 75 to 84; and 0.26 for those 85 or older. Analyses performed for each study year demonstrated results consistent with those for the overall study population.

conclusion: The results of this population-based study suggest that there are substantial opportunities for expanded use of β-blocker therapy in elderly patients who have sustained an acute myocardial infarction.

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Cited by (122)

Has the ClOpidogrel and Metoprolol in Myocardial Infarction Trial (COMMIT) of early β-blocker use in acute coronary syndromes impacted on clinical practice in Canada? Insights from the Global Registry of Acute Coronary Events (GRACE)
2011, American Heart Journal
Citation Excerpt :
However, Emery et al7 did not specifically investigate the use of early BB therapy in hypotensive patients or in patients with STEMI. In our study, patients who did not receive early BB therapy were older and more likely to be female, similar to other studies investigating the use of evidence-based therapies in patients with ACS.7,19-25 Long-term BB use was much higher in the group that received early BB therapy, suggesting that prior BB use may have influenced physicians' decision to administer early BB therapy.
The COMMIT/CCS-2 trial, published in 2005, demonstrated no net benefit of early β-blocker (BB) therapy in acute coronary syndromes (ACS). We sought to assess the short-term impact of this landmark trial by comparing the use of early BB therapy in patients with a broad spectrum of ACS before and after 2005.
Using data from the Global Registry of Acute Coronary Events and Canadian Registry of Acute Coronary Events, we compared the rates of BB use within the first 24 hours of presentation in the periods 1999 to 2005 and 2006 to 2008, after stratifying patients by the type of ACS (ST-segment elevation myocardial infarction [STEMI] and non–ST-segment elevation ACS [NSTEACS]) and clinical presentation.
Of the 14,231 patients with ACS, 77.7% received BB therapy within 24 hours of presentation (78.5% and 77.4% in the STEMI and NSTEACS groups, respectively). The early use of BB declined in the STEMI group (80.3% to 76.7%, P = .005) but increased in the NSTEACS group (75.4% to 78.9%, P < .001) after 2005. Long-term BB use, higher systolic blood pressure, and higher heart rate were independent predictors of early BB use. Conversely, patients who were female, older, Killip class >1, and had cardiac arrest at presentation were less likely to receive early BB. Multivariable analysis showed a trend toward lower use of BB among patients with STEMI (adjusted odds ratio 0.76, 95% CI 0.57-1.00, P = .055) and a trend toward more frequent BB use among patients with NSTEACS (adjusted odds ratio 1.22, 95% CI 0.96-1.55, P = .11) after 2005. The temporal trends in the early use of BB differed between patients with STEMI and patients with NSTEACS (P for interaction with period <.001).
Most patients with STEMI or NSTEACS were treated with early BB therapy. In accordance with the COMMMIT/CCS-2 trial, patients with lower systolic blood pressure and higher Killip class in the “real world” less frequently received early BB therapy. Since the publication of COMMIT/CCS-2, there has been no significant change in the use of BB in patients with STEMI or NSTEACS after controlling for their clinical characteristics.
Comparing clinical and administrative data for profiling hospitals on postdischarge medication use by patients with acute myocardial infarction
2008, American Heart Journal
Postdischarge medication use is frequently used as a measure of hospital performance, with many reports produced using clinical data obtained from chart reviews. The introduction of a drug benefit program administered by the Centers for Medicare and Medicaid Services presents an opportunity to use administrative data for routine reporting on hospital performance. We determined the concordance between hospital-specific prescribing rates of evidence-based medical therapies obtained from clinical and administrative data in Ontario, Canada.
This was a retrospective cohort study using data on patients discharged from 102 hospitals in Ontario, Canada with acute myocardial infarction (AMI) between April 1, 1999, and March 31, 2001. We compared hospital-specific rates of discharge prescribing in AMI patients, determined using clinical data obtained using retrospective chart review with hospital-specific rates of prescriptions filled within 30 days of hospital discharge in elderly patients using administrative data.
There was a moderate agreement between hospital-specific rates of discharge prescriptions written for AMI patients in clinical data with hospital-specific rates of prescriptions filled using administrative data. Although differences in rates were, on average, small between the 2 data sources, there was moderate variation in the differences between these 2 rates across hospitals. There was very strong agreement between rates of discharge prescribing in all patients and in ideal patients with no contraindications, both determined using clinical data.
Post-AMI discharge prescribing in all patients determined using clinical data is an excellent proxy for prescribing in ideal patients using clinical data. However, there is weaker agreement between administrative and clinical data.
Outcome and Quality of Care of Patients who have Acute Myocardial Infarction
2007, Medical Clinics of North America
Citation Excerpt :
Strikingly, outcome differed significantly between the hospitals based on their level of adherence: every decrease in 10% in adherence to guidelines corresponded to a 10% increase in mortality at that hospital. Multiple other studies have documented the underuse of evidence-based therapies in patients who have AMI [16,37–45]. In the NRMI-4, among all patients who had acute NSTEMI who were eligible for glycoprotein (GP) IIb/IIIa inhibitors, only 25% received that therapy, despite the fact that it is a Class I indication in the ACC/AHA guidelines [2].
Coronary artery disease is the number-one killer in developed countries, with lifetime prevalence of up to 50% in American men, and is the topic of much medical literature. Recently, multiple therapies have emerged to save lives after acute myocardial infarction (AMI), backed by well-conducted studies; however, appropriate implementation of therapy guidelines is less than optimal. Recent efforts have focused on improving the quality of care (QC) after AMI in order to improve outcomes. This article illustrates how outcome after AMI is related to QC, describes the underuse of evidence-based therapies, and discusses factors associated with poor guideline adherence. It also reviews current quality improvement projects, and some available means to measure and optimize the QC for patients with AMI.
A quality guarantee in acute coronary syndromes: The American College of Cardiology's Guidelines Applied in Practice program taken real-time
2007, American Heart Journal
Citation Excerpt :
This correlates with better outcomes, both inhospital and at 6-month follow-up, for patients admitted with ACS. Numerous studies have shown that knowledge of or even passive implementation of national guidelines meant to alter physician behavior does not necessarily result in adherence to their use.12-22 In this study, we went beyond simply emphasizing processes of care and tool use by clinicians, but surrounded GAP with real-time analysis which allowed us to provide rapid feedback to clinicians who were then able to modify their practices moment to moment.
Wide variation exists in the management of acute coronary syndromes (ACSs), which includes an apparent underutilization of evidence-based therapies. We have previously demonstrated that application of the American College of Cardiology Guidelines Applied in Practice (GAP) tools can improve quality indicator rates and outcomes of patients hospitalized with ACS.
To determine whether a real-time system for monitoring key quality-of-care indicators using GAP would improve both process indicators and outcomes beyond those of the initial implementation of GAP.
Prospective patient identification, prospective chart coding, retrospective data abstraction.
All patients with ACS admitted (N = 3189) to our institution between January 1, 1999, and December 2004; 2019 studied before real-time implementation from January 1, 1999, to June 30, 2002, and 1170 studied during real-time implementation from July 1, 2002, to December 31, 2004.
The effect of real-time monitoring of key quality indicators on inhospital therapy and outcomes, and 6-month outcomes in patients admitted with ACS.
The real-time GAP implementation correlated with more frequent use of inhospital angiotensin-converting enzyme inhibitors (72.7% vs 63.7%, P < .0001), β blockers (93.0% vs 89.7%, P = .0016), statins (81.2% vs 65.9%, P < .0001), antiplatelet agents (69.2% vs 22.5%, P < .0001), and glycoprotein IIb/IIIa inhibitors (35.5% vs 26.7%, P < .0001). There were fewer episodes of inhospital congestive heart failure (3.85% vs 8.77%, P < .0001) and major bleeding events (3.2% vs 7.9%, P < .0001) after the real-time system was adopted. Real-time GAP also resulted in higher discharge rates of aspirin (92.1% vs 86.5%, P < .0001), β blockers (86.8% vs 79.1%, P < .0001), statins (81.2% vs 64.7%, P < .0001), and angiotensin-converting enzyme inhibitors (67.1% vs 55.5%, P < .0001). Real-time GAP implementation was associated with fewer rehospitalizations for heart disease (19.8% vs 25.2%, P = .0014), myocardial infarction (3.5% vs 5.4%, P = .0243), and combined death/cerebrovascular accident/myocardial infarction (9.5% vs 13.9%, P = .0009) during the first 6 months after discharge.
The institution of a formal system to review and “guarantee” key quality-of-care indicators real time in the hospital is associated with improved outcomes in patients admitted with ACS. The combination of American College of Cardiology's GAP program and its real-time implementation leads to higher use of evidence-based therapies and correspondingly better outcomes than those associated with the initial GAP implementation.
Impact of organizational infrastructure on β-blocker and aspirin therapy for acute myocardial infarction
2006, American Heart Journal
Although organizational change has been advocated as a critical component of quality improvement, there is little data available on the variation and effectiveness of organizational elements in the care of acute myocardial infarction (AMI).
This study was designed to examine the impact of organizational infrastructure on the use of aspirin and β-blockers during and after AMI.
We assessed organizational infrastructure for AMI care in 44 hospitals in Kansas and linked these data to patient-specific process of care data collected in Kansas as part of the Cooperative Cardiovascular Project. While controlling for clustering within hospitals, we examined the relationships between hospital infrastructure and use of aspirin and β-blocker both at admission and discharge.
Hospitals varied widely in their inclusion of aspirin and β-blockers in AMI pathways, protocols, and standardized order sets. Hospitals also varied in the involvement of their physicians in AMI quality improvement and in their ability to identify a physician champion for AMI care. Patients were more likely to receive aspirin on admission in hospitals that included aspirin in their emergency department order sets (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.48) and were more likely to receive β-blockers on admission and at discharge if β-blockers were included in an emergency department protocol or pathway (OR 2.14, 95% CI 1.25-3.77 and OR 3.5, 95% CI 1.14-14.38, respectively). Use of β-blockers at discharge was also associated with commitment of administration to AMI care and the presence of a physician champion.
Quality improvement efforts should include a close examination of the organization of AMI care to assure that critical elements in the care of AMI patients are not inadvertently omitted.
β-Blocker use in elderly ED patients with acute myocardial infarction
2006, American Journal of Emergency Medicine
Despite the effectiveness of early β-blocker (BB) use in reducing mortality in acute myocardial infarction (AMI), they remain underutilized in the emergency department (ED) management of AMI. The elderly, with higher AMI mortality, and women, may be particularly vulnerable to underutilization of BB.
To determine the effect of age and gender on BB use in AMI in the ED.
A retrospective study of all ST-elevation AMI (STEMI) ED patients presenting to a community hospital ED from 2001 to 2003. Any contraindication to BB use (hypotension, bradycardia, AV block, active bronchospasm, and active congestive heart failure) was determined. Chi-square analysis was used to determine differences by gender and age.
Three hundred eighty-five patients with STEMI were identified. Thirty-eight percent were women and 71% were over 60 years of age. Of the 270 (70%) who did not receive BB, 141 (52%) had contraindications to BB use. The total BB eligible group was 244 (63%). Of patients without contraindications to BB, 53% did not receive BB in the ED. By gender, 83 (54%) males and 46 (51%) females did not receive BB (P= .669). By age, 96 subjects (59%) over age 60 and 33 subjects (41%) under age 60 did not receive BB (P= .011).
Despite convincing evidence of effectiveness, BB remain underutilized in ED management of AMI, especially in the elderly. There does not appear to be a gender difference in BB use. Education programs should be directed towards emergency physicians regarding BB use in AMI, especially in elderly ED patients.

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^☆: This project was supported by NHLBI Grant RO1 HL-35434 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

¹: Dr. Gurwitz is the recipient of a Clinical Investigator Award (K08 AG00510) from the National Institute on Aging, Bethesda, Maryland.

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β-Blocker therapy in acute myocardial infarction: Evidence for underutilization in the elderly☆

Abstract

Lancet

Prog Cardiovasc Dis

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am J Med

Am J Med

Metoprolol in acute myocardial infarction (MIAMI): a randomized placebo-controlled international trial

Eur Heart J

Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-1

Lancet

Overview of results of randomized clinical trials in heart disease: I. Treatments following myocardial infarction

JAMA

Adjunctive use of beta-adrenergic blockers, calcium antagonists and other therapies in coronary thrombolysis

Am J Cardiol