Post-MI Beta-blockers in Frail Elderly: Longer, Lower-Quality Survival

Marlene Busko

December 14, 2016

SAN FRANCISCO, CA — Among older patients in nursing homes who had had an MI, those who received a beta-blocker had a 26% lower mortality rate at 3 months compared with patients who did not receive this therapy[1].

But in the patients with the worst initial cognition and functional status, beta-blocker therapy was associated with a 33% increased odds of having a major decline in ability to perform activities of daily living independently.

These findings by Dr Michael A Steinman (University of California, San Francisco) and colleagues were published December 12, 2016 in JAMA Internal Medicine.

"We found that, just as in younger, more robust adults, beta-blockers do extend life after MI" in nursing-home patients, but "in the frailest adults, those with relatively high levels of cognitive impairment or functional impairment, beta-blockers seemed to be increasing functional decline—so we have a trade-off," Steinman told heartwire from Medscape.

"I want to emphasize that this applies only to the most vulnerable people," Steinman stressed. There was no trade-off in patients with better cognitive and functional status, so the prescribing decision for those patients is less ambiguous, he added. "Interestingly, age had nothing to do with it."

"The authors confirmed that the practice of avoiding prescription of beta-blockers in frail and highly vulnerable elders with functional impairment is reasonable, [and they] extend that knowledge one step further," Drs Jennifer Tjia and Kate Lapane (University of Massachusetts Medical School, Worcester) summarize in an accompanying editorial[2].

That is, Steinman and colleagues "shed some light on where the tipping point is" for the balance between benefits and risks of beta-blocker therapy in nursing-home patients who have had an MI.

Invited to comment, Dr Paula Rochon (Women's College Hospital and University of Toronto, Ontario) added that importantly, this study highlights the need to make prescribing decisions for nursing-home patients based on the goals of care for an individual patient.

For the most vulnerable patients "who really value preserving as much independence as they have and whose primary goal isn't life extension but is quality of life and being able to preserve what they have, in those patients, it might be quite reasonable to withhold beta-blockers," Steinman agreed.

"Good Prescribing Is a Balancing Act"

Guidelines recommend giving beta-blockers to adults who have had an MI, and this therapy reduced mortality by 25% to 30% in clinical trials, Steinman and colleagues write.

However, beta-blockers are commonly not prescribed to older nursing-home residents after they have an MI, partly due to concerns that the patient will experience orthostasis, fatigue, and depression, and possibly lose ability to function independently.

"Guidelines don't differentiate between these frail older adults [with moderate and severe functional and cognitive impairment] and everyone else," Steinman noted. They "do acknowledge that you need to individualize care, and we lack the evidence in old people, but this doesn't really tell us what to do in old people."

To investigate this, the researchers examined date from 15,720 patients aged 65 and older who lived in nursing homes in the US and had an MI between 2007 and 2010. The patients had a mean age of 83, and 71% were women.

Prior to their MI, about a third were able to perform activities of daily living with limited assistance, if any; a third required extensive assistance, and a third were totally dependent on help. Close to a third (30%) had intact cognition; 52% had mild to moderate dementia; and 18% had severe dementia.

After their MI, 8953 patients (60%) were initiated on a beta-blocker and 6767 patients (40%) did not receive a beta-blocker.

The primary outcome was a 3-point decline in the Morris scale of independence in activities of daily living. This scale looks at ability to perform seven activities of daily living without help and assigns a score of 0 to 4, for a maximum score of 28, Steinman explained. A 3-point drop can indicate a substantial decline in one of these activities or a milder decline in multiple domains.

Other key outcomes were death and rehospitalization within 90 days of the hospital discharge.

Within 3 months after hospital discharge, 12% of patients experienced a functional decline, 25% were rehospitalized, and 14% had died.

Patients who had received beta-blockers were more likely to experience a major functional decline, but they were also more likely to survive, and they had similar rates of rehospitalization as the other patients.

Odds of Outcomes at 3 Months, Beta-blocker Users vs Nonusers

Outcome

Odds ratio (95% CI)

NNT/NNH

Functional decline

1.14 (1.02–1.28)

NNH 52

Death

0.74 (0.67–0.83)

NNT 26

Rehospitalization

1.06 (0.98–1.14)

NNH 82

NNT=number needed to treat
NNH=number needed to harm

In the subgroup of nursing-home residents with moderate or severe dementia (roughly corresponding to a Folstein Mini-Mental State Examination score of ≤14 of 30 points), those who received beta-blockers were more likely to experience functional decline (OR 1.34, 95% CI 1.11–1.61), with a number needed to harm of 36.

Similarly, patients with severe functional dependence to start with who received beta-blockers were also more likely to experience functional decline (OR 1.32, 95% CI 1.10–1.59), with a number needed to harm of 25.

In contrast, there was very little evidence of functional decline associated with beta-blockers in participants with intact cognition or mild dementia or in those in the top two tertiles of functional independence.

"This is a large population; more than half of nursing-home residents have high levels of functional dependence, and two-thirds have moderate or severe cognitive impairment," the researchers point out, and this study should help shed light on this one prescribing decision.

"Good prescribing is a balancing act that is as much art as a science," the editorialists write. They add that the present study adds to the science but has limitations inherent to observational studies and say that more study is also needed to determine how long beta-blocker therapy should be continued after an MI in frail, impaired elderly patients.

Steinman is a consultant for Iodine.com. Disclosures for the coauthors are listed in the article. Tjia received grants from the National Institutes of Health (NIH), the Donaghue Foundation, the Arnold P Gold Foundation, and the Cambia Health Foundation. She received honoraria from the Donaghue Foundation and honoraria and travel support from CVS Omnicare, and she is a consultant for CVS Caremark Pharmacy. Lapane received grants from the NIH, the Centers for Disease Control and Prevention, and Cubist Pharmaceuticals.

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