β-blocker dosage and outcomes after acute coronary syndrome

Jason E. Allen, Stacey Knight, Raymond O. McCubrey, Tami Bair, Joseph Brent Muhlestein, Jeffrey Goldberger, Jeffrey L. Anderson

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Background Although β-blockers increase survival in acute coronary syndrome (ACS) patients, the doses used in trials were higher than doses used in practice, and recent data do not support an advantage of higher doses. We hypothesized that rates of major adverse cardiac events (MACE), all-cause death, myocardial infarction, and stroke are equivalent for patients on low-dose and high-dose β-blocker. Methods Patients admitted to Intermountain Healthcare with ACS and diagnosed with ≥70% coronary stenosis between 1994 and 2013 were studied (N = 7,834). We classified low dose as ≤25% and high dose as ≥50% of an equivalent daily dose of 200 mg of metoprolol. Multivariate analyses were used to test association between low-dose versus high-dose β-blocker dosage and MACE at 0-6 months and 6-24 months. Results A total of 5,287 ACS subjects were discharged on β-blockers (87% low dose, 12% high dose, and 1% intermediate dose). The 6-month MACE outcomes rates for the β-blocker dosage (low versus high) were not equivalent (P = .18) (hazard ratio [HR] = 0.76; 95% CI, 0.52-1.10). However, subjects on low-dose β-blocker therapy did have a significantly decreased risk of myocardial infarction for 0-6 months (HR = 0.53; 95% CI, 0.33-0.86). The rates of MACE events during the 6-24 months after presentation with ACS were equivalent for the 2 doses (P = .009; HR = 1.03 [95% CI, 0.70-1.50]). Conclusions In ACS patients, rates of MACE for high-dose and low-dose β-blocker doses are similar. These findings question the importance of achieving a high dose of β-blocker in ACS patients and highlight the need for further investigation of this clinical question.

Original languageEnglish (US)
Pages (from-to)26-36
Number of pages11
JournalAmerican Heart Journal
Volume184
DOIs
StatePublished - Feb 1 2017

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Acute Coronary Syndrome
Myocardial Infarction
Metoprolol
Coronary Stenosis
Cause of Death
Multivariate Analysis
Stroke
Delivery of Health Care
Survival

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Allen, J. E., Knight, S., McCubrey, R. O., Bair, T., Muhlestein, J. B., Goldberger, J., & Anderson, J. L. (2017). β-blocker dosage and outcomes after acute coronary syndrome. American Heart Journal, 184, 26-36. https://doi.org/10.1016/j.ahj.2016.10.012

β-blocker dosage and outcomes after acute coronary syndrome. / Allen, Jason E.; Knight, Stacey; McCubrey, Raymond O.; Bair, Tami; Muhlestein, Joseph Brent; Goldberger, Jeffrey; Anderson, Jeffrey L.

In: American Heart Journal, Vol. 184, 01.02.2017, p. 26-36.

Research output: Contribution to journalArticle

Allen, JE, Knight, S, McCubrey, RO, Bair, T, Muhlestein, JB, Goldberger, J & Anderson, JL 2017, 'β-blocker dosage and outcomes after acute coronary syndrome', American Heart Journal, vol. 184, pp. 26-36. https://doi.org/10.1016/j.ahj.2016.10.012
Allen, Jason E. ; Knight, Stacey ; McCubrey, Raymond O. ; Bair, Tami ; Muhlestein, Joseph Brent ; Goldberger, Jeffrey ; Anderson, Jeffrey L. / β-blocker dosage and outcomes after acute coronary syndrome. In: American Heart Journal. 2017 ; Vol. 184. pp. 26-36.
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abstract = "Background Although β-blockers increase survival in acute coronary syndrome (ACS) patients, the doses used in trials were higher than doses used in practice, and recent data do not support an advantage of higher doses. We hypothesized that rates of major adverse cardiac events (MACE), all-cause death, myocardial infarction, and stroke are equivalent for patients on low-dose and high-dose β-blocker. Methods Patients admitted to Intermountain Healthcare with ACS and diagnosed with ≥70{\%} coronary stenosis between 1994 and 2013 were studied (N = 7,834). We classified low dose as ≤25{\%} and high dose as ≥50{\%} of an equivalent daily dose of 200 mg of metoprolol. Multivariate analyses were used to test association between low-dose versus high-dose β-blocker dosage and MACE at 0-6 months and 6-24 months. Results A total of 5,287 ACS subjects were discharged on β-blockers (87{\%} low dose, 12{\%} high dose, and 1{\%} intermediate dose). The 6-month MACE outcomes rates for the β-blocker dosage (low versus high) were not equivalent (P = .18) (hazard ratio [HR] = 0.76; 95{\%} CI, 0.52-1.10). However, subjects on low-dose β-blocker therapy did have a significantly decreased risk of myocardial infarction for 0-6 months (HR = 0.53; 95{\%} CI, 0.33-0.86). The rates of MACE events during the 6-24 months after presentation with ACS were equivalent for the 2 doses (P = .009; HR = 1.03 [95{\%} CI, 0.70-1.50]). Conclusions In ACS patients, rates of MACE for high-dose and low-dose β-blocker doses are similar. These findings question the importance of achieving a high dose of β-blocker in ACS patients and highlight the need for further investigation of this clinical question.",
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AU - Anderson, Jeffrey L.

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N2 - Background Although β-blockers increase survival in acute coronary syndrome (ACS) patients, the doses used in trials were higher than doses used in practice, and recent data do not support an advantage of higher doses. We hypothesized that rates of major adverse cardiac events (MACE), all-cause death, myocardial infarction, and stroke are equivalent for patients on low-dose and high-dose β-blocker. Methods Patients admitted to Intermountain Healthcare with ACS and diagnosed with ≥70% coronary stenosis between 1994 and 2013 were studied (N = 7,834). We classified low dose as ≤25% and high dose as ≥50% of an equivalent daily dose of 200 mg of metoprolol. Multivariate analyses were used to test association between low-dose versus high-dose β-blocker dosage and MACE at 0-6 months and 6-24 months. Results A total of 5,287 ACS subjects were discharged on β-blockers (87% low dose, 12% high dose, and 1% intermediate dose). The 6-month MACE outcomes rates for the β-blocker dosage (low versus high) were not equivalent (P = .18) (hazard ratio [HR] = 0.76; 95% CI, 0.52-1.10). However, subjects on low-dose β-blocker therapy did have a significantly decreased risk of myocardial infarction for 0-6 months (HR = 0.53; 95% CI, 0.33-0.86). The rates of MACE events during the 6-24 months after presentation with ACS were equivalent for the 2 doses (P = .009; HR = 1.03 [95% CI, 0.70-1.50]). Conclusions In ACS patients, rates of MACE for high-dose and low-dose β-blocker doses are similar. These findings question the importance of achieving a high dose of β-blocker in ACS patients and highlight the need for further investigation of this clinical question.

AB - Background Although β-blockers increase survival in acute coronary syndrome (ACS) patients, the doses used in trials were higher than doses used in practice, and recent data do not support an advantage of higher doses. We hypothesized that rates of major adverse cardiac events (MACE), all-cause death, myocardial infarction, and stroke are equivalent for patients on low-dose and high-dose β-blocker. Methods Patients admitted to Intermountain Healthcare with ACS and diagnosed with ≥70% coronary stenosis between 1994 and 2013 were studied (N = 7,834). We classified low dose as ≤25% and high dose as ≥50% of an equivalent daily dose of 200 mg of metoprolol. Multivariate analyses were used to test association between low-dose versus high-dose β-blocker dosage and MACE at 0-6 months and 6-24 months. Results A total of 5,287 ACS subjects were discharged on β-blockers (87% low dose, 12% high dose, and 1% intermediate dose). The 6-month MACE outcomes rates for the β-blocker dosage (low versus high) were not equivalent (P = .18) (hazard ratio [HR] = 0.76; 95% CI, 0.52-1.10). However, subjects on low-dose β-blocker therapy did have a significantly decreased risk of myocardial infarction for 0-6 months (HR = 0.53; 95% CI, 0.33-0.86). The rates of MACE events during the 6-24 months after presentation with ACS were equivalent for the 2 doses (P = .009; HR = 1.03 [95% CI, 0.70-1.50]). Conclusions In ACS patients, rates of MACE for high-dose and low-dose β-blocker doses are similar. These findings question the importance of achieving a high dose of β-blocker in ACS patients and highlight the need for further investigation of this clinical question.

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