Beta-Blockers After Heart Attacks Could Save Lives

December 05, 2000
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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 UCSF Medical Center.

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 that reduce the heart rate and decrease the strength of the heart's contraction.

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 for breast cancer of a similar-sized population every year over the next two decades, the researchers report in the Dec. 6 issue of the Journal of the American Medical Association (JAMA).

Senior author on the study is Dr. Lee Goldman, a specialist in cardiovascular medicine at UCSF Medical Center and a UCSF professor and chair of medicine.

"Our study re-emphasizes the 'lost opportunity' that results from the under-use of medications that are both effective and cost-effective," Goldman said. "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."

The 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 10 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, lead author on the study and associate professor of health economics and health services research in the UCSF clinical pharmacy department.

The research draws on a well-respected model of cardiac health disease in the United States, 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 the 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.

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, researchers found that such an increase in prescribing beta-blockers would not be prohibitively costly. The net cost was estimated to be $158 million. 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 money."

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