Original Investigation
Hypertension and Acid-Base/Electrolyte Disorders
Kidney Function and Population-Based Outcomes of Initiating Oral Atenolol Versus Metoprolol Tartrate in Older Adults

https://doi.org/10.1053/j.ajkd.2014.06.009Get rights and content

Background

Atenolol and metoprolol tartrate are commonly prescribed β-blockers. Atenolol elimination depends on kidney function, whereas metoprolol tartrate does not. We hypothesized that compared to metoprolol tartrate, initiating oral atenolol treatment would be associated with more adverse events in older adults, with the association most pronounced in patients with lower baseline estimated glomerular filtration rates (eGFRs).

Study Design

Population-based matched retrospective cohort study.

Setting & Participants

Older adults (mean age, 75 years) in Ontario, Canada, prescribed oral atenolol versus metoprolol tartrate from April 2002 through December 2011. The 2 groups were well matched (n = 75,257 in each group), with no difference in 31 measured baseline characteristics. Patients with end-stage renal disease were ineligible, and 4.6% of patients had chronic kidney disease (median eGFR, 38 mL/min/1.73 m2 assessed through a database algorithm).

Predictors

β-Blocker type and eGFR.

Outcomes

A composite outcome of hospitalization with bradycardia or hypotension and all-cause mortality were assessed in 90-day follow-up.

Results

Compared to metoprolol tartrate, initiating atenolol treatment was not associated with higher risk of hospitalization with bradycardia or hypotension (incidence, 0.71% vs 0.79%; relative risk, 0.90; 95% CI, 0.80-1.01). Atenolol treatment initiation was associated with lower 90-day risk of mortality than metoprolol tartrate (incidence, 0.97% vs 1.44%; relative risk, 0.68; 95% CI, 0.61-0.74). Lower eGFR did not modify either association (P for interaction = 0.5 and 0.6, respectively).

Limitations

Heart rate and blood pressure were not available in our data sources, and effects ascertained from observational studies are subject to residual confounding.

Conclusions

Contrary to our expectation, we found that atenolol versus metoprolol tartrate was associated with lower 90-day risk of mortality in patients regardless of eGFR, with no difference in risk of hospitalization with bradycardia or hypotension.

Section snippets

Design and Setting

We conducted a population-based retrospective matched-cohort study of older adults using linked health care databases in Ontario, Canada, held at the Institute for Clinical Evaluative Sciences. Ontario has approximately 1.8 million adults 65 years or older who have comprehensive health care coverage that includes outpatient drug prescriptions, physician services, and hospitalizations under a single-payer health care system.10 We conducted this study according to a prespecified protocol that was

Study Participants

Cohort selection is presented in Fig S1. We identified 233,272 patients initiated on atenolol (n = 114,706) or metoprolol tartrate treatment (n = 118,566). After matching, we retained 75,257 patients prescribed each of the 2 β-blockers. Baseline characteristics of patients before and after the match are presented in Table 1. Baseline characteristics of the 2 β-blocker groups after matching were nearly identical (standardized differences for 31 characteristics were <6%). The 2 groups were well

Discussion

Patients with lower eGFRs prescribed the oral β-blocker atenolol, which is eliminated by the kidneys, are thought to be prone to adverse events from potential drug accumulation. However, in this observational study, a new outpatient prescription for oral atenolol in elderly patients was not associated with a significantly higher 90-day risk of hospitalization with bradycardia or hypotension compared to metoprolol tartrate. Although these events were more common in patients with lower eGFRs than

Acknowledgements

We thank Brogan Inc, Ottawa, for use of its Drug Product and Therapeutic Class Database.

Support: This project was conducted at the Institute for Clinical Evaluative Sciences (ICES) Western Site. ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). ICES Western is funded by an operating grant from the Academic Medical Organization of Southwestern Ontario. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. The opinions,

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