Wider use of beta-blockers after heart attacks could save thousands of lives at a reasonable cost, n

By Wallace Ravven

Thousands of lives would be spared if physicians prescribed beta-blockers for
more people who have had heart attacks, according to a new study led by
researchers at the University of California San Francisco (UCSF).

Providing beta-blockers to most people who have had heart attacks would save
seven times more years of life by 2020 than will be saved through mammography
screening of a similar-sized population every year over the next two decades,
the researchers report in the December 6 issue of the Journal of the American
Medical Association (JAMA).

Their study projects more than 4,000 lives saved from coronary disease and
3,500 heart attacks averted over 20 years at a reasonable cost simply by
providing beta-blockers to those who are “eligible” among current heart attack
survivors - about 92 percent of those with heart attacks.

“Most clinicians and other health professionals have known for ten years or
more that beta-blockers can play a dramatic role in saving lives and sparing
more heart attacks, but for a combination of reasons, the practice has not been
widely adopted,” said Kathryn A. Phillips, PhD, lead author on the study and
associate professor of health economics and health services research in the
UCSF clinical pharmacy department, School of Pharmacy.

“I hope this study proves to be an impetus to increase the use of beta-blockers
for all those who can benefit from them.”

Senior author on the study is Lee Goldman, MD,  MPH, professor and chair of
medicine at UCSF.

The research draws on a well-respected model of cardiac health disease in the
U.S., known as the Coronary Heart Disease Policy Model, which incorporates
national census data and the principal known health risk factors for heart
disease. The model has been validated by comparing predicted mortality against
actual mortality and has been shown to predict outcomes within two percent.

The National Center for Quality Assurance, which accredits managed care
organizations, considers use of beta-blockers as an indicator of high-quality
health care, but a combination of public misapprehensions about side effects,
heavy marketing of related drugs, and uncertainty among some physicians has
stalled widespread use of beta-blockers, Phillips explained.

Serious side effects - fatigue, sexual dysfunction and depression - are
uncommon, probably occurring in less than one-tenth of patients, but the “word
on the street” seems to be that the frequency of side effects is much higher,
Phillips said.  In addition, drug manufacturers aggressively market and
physicians widely prescribe a more expensive, related class of drugs - calcium
channel blockers—although many physicians don’t realize that these
medications are not appropriate substitutes for beta-blockers, Phillips added.

Beta-blockers - technically beta-adrenergic blocking agents - are prescribed to
treat high blood pressure and angina pain, and they are used for heart failure
and after heart attacks. They work by blocking the stimulation of certain
receptors which reduces the heart rate and decreases the strength of the heart’
s contraction.

The study projected the benefits in decreased disease and lives saved by
providing beta-blockers to all who have had heart attacks except those with the
most severe conditions or who are allergic to the medicine. This is about 92
percent of heart attack survivors, or about 400,000 people annually in the U.S.

Because beta-blockers are available as generic drugs, the researchers found
that such an increase in prescribing beta-blockers would not be prohibitively
costly. The net cost was estimated to be $158 million. However, since
beta-blockers can be purchased as generics for less than $300 per person
annually, their increased use would actually save money over the 20 years
studied due to lower medical costs.

“The value of beta-blockers has already been clinically proven,” said Phillips.
“But what has not been as clear is the value from a societal perspective. This
study goes a long way to show that increased use of beta-blockers to the target
population will save lives at a reasonable cost, and in some cases, will save

“Our study re-emphasizes the ‘lost opportunity’ that results from the under-use
of medications that are both effective and cost-effective,” said Lee Goldman.
“Current practice has yielded only about 55 percent of the potential benefit of
beta-blockers for survivors of heart attack. It is critical that our quest for
new therapies not distract us from taking fullest advantages of the
already-proven ones.”

Collaborators on the research and co-authors with Phillips and Goldman on the
JAMA paper are Michael Shlipak, MD, MPH, assistant professor, and Pam Coxson,
PhD, mathematics specialist, both in the department of medicine at UCSF; Paul
Heidenreich, MD, assistant professor of medicine and cardiovascular medicine at
Stanford University; M.G. Myriam Hunink, PhD, professor of clinical epidemiology,Erasmus University, The Netherlands and adjunct professor of health policy,Harvard University; Paula Goldman, MPH, specialist, and Milton Weinstein, PhD,professor of health policy and management, both at the Harvard School of Public Health;and Lawrence Williams, MS, specialist, Brigham and Women’s Hospital.