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 -Blocker Dosages and Mortality After Myocardial Infarction
Data From a Large Health Maintenance Organization
Hal V. Barron, MD;
Sami Viskin, MD;
Robert J. Lundstrom, MD;
Bix E. Swain, MS;
Alison F. Truman, MS;
Candice C. Wong, MD;
Joe V. Selby, MD
Arch Intern Med. 1998;158:449-453.
Background Although long-term  -blocker therapy has been found beneficial in patients after an acute myocardial infarction, these drugs are greatly underused by clinicians. Moreover, the dosages of -blockers used in randomized controlled trials appear to be much larger than those routinely prescribed.
Objective To determine whether an association exists between the dosage of -blockers prescribed after a myocardial infarction and cardiac mortality.
Methods We performed a retrospective cohort study of 1165 patients who survived an acute myocardial infarction from January 1, 1990, through December 31, 1992. These patients represent a subgroup of the 6851 patients hospitalized at northern California Kaiser Permanente hospitals.
Results Of the 37.7% of patients prescribed -blocker therapy, 48.1% were treated with dosages less than 50% of the dosage found to be effective in preventing cardiac death in large randomized clinical trials (lower-dosage therapy). Compared with patients not receiving -blockers, those treated with lower-dosage therapy appeared to have a greater reduction in cardiovascular mortality (hazard ratio, 0.33; P=.009) than patients treated with a higher dosage (hazard ratio, 0.82; P=0.51), after adjustment for age, sex, race, disease severity, and comorbidities.
Conclusions The dosages of -blockers shown to be effective in randomized trials are not commonly used in clinical practice, and treatment with lower dosages of -blockers was associated with at least as great a reduction in mortality as treatment with higher dosages. This suggests that physicians who are reluctant to prescribe -blockers because of the relatively large dosages used in the large prospective clinical trials should be encouraged to prescribe smaller dosages.
From the Department of Medicine and Cardiovascular Research Institute, University of California, San Francisco (Drs Barron and Viskin), and Division of Research, Kaiser Permanente, Oakland, Calif (Drs Lundstrom, Wong, and Selby, Mr Swain, and Ms Truman).
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