Patient-Important Adverse Events of β-blockers in Frail Older Adults after Acute Myocardial Infarction

Abstract

Background We evaluated the burden of adverse events caused by β-blocker use after acute myocardial infarction (AMI) in frail, older nursing home (NH) residents. Methods This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population was individuals aged ≥65 years who resided in a U.S. NH for ≥30 days, had a hospitalized AMI between May 2007 and March 2010, and returned to the NH. Exposure was new use of β-blockers versus nonuse post-AMI. Orthostasis, general hypotension, falls, dizziness, syncope, and breathlessness outcomes were measured over 90 days of follow-up. Odds ratios (ORs) with 95% confidence intervals (CIs) for outcomes were estimated using multinomial logistic regression models after 1:1 propensity score-matching of β-blocker users to nonusers. Results Among the 10,992 NH propensity score-matched residents with an AMI, the mean age was 84 years and 70.9% were female. β-blocker users were more likely than nonusers to be hospitalized for hypotension (OR = 1.20, 95% CI 1.03–1.39) or experience breathlessness (OR = 1.10, 95% CI 1.01–1.20) after AMI. With the exception of falls, other outcome estimates, though imprecise, were compatible with a potential elevated risk of orthostasis (OR = 1.14, 95% CI 0.96–1.35), syncope, (OR = 1.24, 95% CI 0.55–2.77), and dizziness (OR = 1.28, 95% CI 0.82–1.99) among β-blocker users. Conclusions Considered alongside prior evidence that β-blockers may worsen functional outcomes in NH residents with poor baseline functional and cognitive status, our results suggest that providers should exercise caution when prescribing for these vulnerable groups, balancing the mortality benefit against the potential for causing adverse events.

Association Between Secondary Prevention Medication Use and Outcomes in Frail Older Adults After Acute Myocardial Infarction

“…16 Our findings suggest that prescribing more guideline-recommended medications is indicated for frail, older adults who wish to maximize longevity after AMI. 19,30 Although data on the use of more versus fewer secondary prevention medications in frail, older adults is lacking, our study is consistent with two studies using older data to examine the associations between secondary prevention medications and mortality in older community-dwelling adults. 10,31 The non-U.S. populations in these studies are younger and much less frail than our population of NH residents.…”

How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

“…The initiation of beta-blockers after myocardial infarction has, for instance, been found to be associated with a reduction of mortality and also with a worsening of functional outcomes among nursing home residents, especially among those with moderate-to-severe cognitive impairment or severe functional limitations. 48,49 Our finding that older adults at high risk of frailty were less likely to initiate but more likely to continue drugs of questionable benefit at the end of life should give pause. It illustrates the ability of clinicians to recognize the futility of initiating disease-oriented drugs for these patients, but their difficulty to discontinue these same drugs once they have been initiated -a phenomenon closely related to what is known as the 'endowment bias' in behavioural economics.…”

Indications for β‐Blocker Prescriptions in Heart Failure with Preserved Ejection Fraction

“…In a study of over 15 000 nursing home residents, BBs were associated with functional decline specifically among those with cognitive or functional impairment. Furthermore, BBs increase the risk for adverse drug reactions requiring a hospitalization, and thus may not be ideal for individuals with geriatric conditions who are at high risk for experiencing adverse drug reactions . Accordingly, the risk‐benefit ratio of BBs, especially for individuals who lack compelling indications, may favor harm in many HFpEF patients.…”

“…12 In a study of over 15 000 nursing home residents, BBs were associated with functional decline specifically among those with cognitive or functional impairment. Furthermore, BBs increase the risk for adverse drug reactions requiring a hospitalization, 11,30 and thus may not be ideal for individuals with geriatric conditions who are Figure 1. Indications for β blockers (BBs) prescribed at discharge following a heart failure with preserved ejection fraction (HFpEF) hospitalization.…”