Researchers find beta blockers reduce death risk but impair function after heart attack

December 13, 2016 by Scott Maier
heart
Human heart. Credit: copyright American Heart Association

Beta blockers are effective in reducing the risk of death in older nursing home residents after a heart attack, but may impair their ability to perform daily functions independently, according to a new study by researchers at UC San Francisco. They recommend that clinicians weigh potential benefits with risks before prescribing these medications.

Their study, which appears Dec. 12, 2016, in JAMA Internal Medicine, assessed nearly 11,000 nursing home residents who had suffered a , half of whom received beta blocker drugs afterwards, and analyzed mortality, as well as hospital readmissions and quality of life. While the drugs reduced the death toll by about a quarter, they also were associated with up to a 34 percent increase in the risk of impaired function among residents with moderate or severe dementia.

"There is a lot of interest in the potential harms of drugs in and how they affect one's quality of life by contributing to problems such as fatigue, dizziness and a general sense of being off," said senior author Michael Steinman, MD, professor of geriatrics at UCSF and the affiliated San Francisco VA Health Care System. "Our results present a paradigm for thinking about how the potential mortality benefits of drugs can be balanced by harms to quality of life in older adults and how to manage that risk-benefit tradeoff."

Beta blockers are widely prescribed to treat high blood pressure, congestive heart failure, abnormal heart rhythms and chest pain. Randomized trials have shown their use after a heart attack reduces mortality by 25-30 percent, and many observational studies have found a similar level of mortality reduction in adults 85 and older and in those with functional impairments such as difficulty in bathing, getting out of a chair and dressing themselves.

Despite the benefits of beta blockers across the age span, they are less often prescribed to older adults. There also are little data on potential adverse effects, such as dizziness with standing, fatigue and depression, in frail and highly vulnerable elders, which can negatively impact daily functioning and quality of life.

The dilemma of beta blocker benefits vs. harms is particularly important for the estimated 1.4 million Americans in nursing homes, who are at high risk of and often strongly value preserving their remaining functional independence.

In the JAMA Internal Medicine study, Steinman and his colleagues conducted an observational study of nursing home residents age 65 and older who were hospitalized for a heart attack between May 1, 2007, and March 31, 2010, using national data from the Minimum Data Set (MDS), the Online Survey Certification and Reporting System (OSCAR), and Medicare Part A and D (prescription drug benefit) claims. The MDS comprises assessments made on nearly all U.S. nursing home residents. OSCAR provides facility-level information on nursing home characteristics, staffing and quality indicators.

With an average patient age of 84, the study cohort included 5,496 new beta blocker users and an equal number of non-users. Qualifying patients had resided in a nursing home for at least 30 days prior to hospitalization, were not using a beta blocker for at least four months prior to hospitalization and returned to a nursing home after discharge.

Steinman and his team analyzed patients who used a beta blocker in the immediate post-hospital period in relation to functional decline. This decline was defined as a certain drop in a validated scale of independence in activities of daily living between the pre-hospital baseline and first available assessment following hospitalization, up to three months after discharge. Also measured were death and re-hospitalization.

Overall, beta blockers reduced 90-day mortality by 26 percent in all types of nursing home residents. But their use increased the odds of functional decline by 14 percent.

These harms to daily functioning were concentrated in nursing home residents who had substantial levels of cognitive or functional impairment at baseline. Specifically, beta blockers increased the odds of functional decline by 32-34 percent in patients with moderate or severe dementia, and in those who were highly dependent on others to do basic daily activities such as dressing and bathing.

In contrast, beta blockers had no impact on daily functioning among people who had normal cognition or mild dementia, and in people who were not highly dependent on others to perform basic daily activities.

For nursing home residents with extensive functional dependency or moderate to severe dementia, the decision to use beta blockers should depend on patient preferences, either expressed directly or through surrogate decision-makers, Steinman said. For cognitively or functionally impaired nursing home residents who are more concerned about functional decline than death, avoiding treatment may be preferred.

"Randomized controlled trials are often ideal for studying the effects of treatments like ," said author Andrew Zullo, PharmD, ScM, investigator in health services, policy and practice at Brown University School of Public Health. "But, conducting a trial would be difficult for nursing home residents with a myocardial infarction. In the absence of a trial, our rigorous observational study is critical for providing necessary evidence about the trade-off between longevity and functioning when starting a beta blocker medication."

Explore further: Many nursing home residents not taking beta-blockers after AMI

Related Stories

Many nursing home residents not taking beta-blockers after AMI

November 23, 2016
(HealthDay)—Many nursing home (NH) residents do not initiate beta-blocker use after acute myocardial infarction (AMI), according to a study published online Nov. 15 in the Journal of the American Geriatrics Society.

Palliative care may mean fewer difficult transitions for older adults nearing end of life

November 18, 2016
Palliative care is treatment—such as medication, nutritional support, or massage—that helps you feel better when you have a serious illness. Palliative care can help ease pain, insomnia, shortness of breath, nausea, and ...

What impact do medication errors have on nursing home residents?

November 21, 2016
A new analysis points to surprisingly low rates of serious impacts from medication errors affecting nursing home residents, despite the fact that these errors remain fairly common. The investigators noted that it's unclear ...

Does obesity lead to more nursing home admission and a lower quality of care?

May 31, 2016
In a study published in the Journal of the American Geriatrics Society, researchers examined the care that obese older adults receive when they are admitted to nursing homes.

Beta-blockers following angioplasty show little benefit for some older patients

August 15, 2016
Following coronary angioplasty, beta-blockers did not significantly improve mortality rates or reduce the number of future cardiovascular incidents for older patients with stable angina but no history of heart attack or heart ...

Half of long-stay nursing home residents go to hospital ED regardless of cognitive status

April 19, 2016
A new study from the Indiana University Center for Aging Research and the Regenstrief Institute has found that almost half of all long-stay nursing home residents experience at least one transfer to an Emergency Department ...

Recommended for you

Laser device placed on the heart identifies insufficient oxygenation better than other measures

September 20, 2017
A new device can assess in real time whether the body's tissues are receiving enough oxygen and, placed on the heart, can predict cardiac arrest in critically ill heart patients, report researchers at Boston Children's Hospital ...

Metabolism switch signals end for healing hearts

September 19, 2017
Researchers have identified the process that shuts down the human heart's ability to heal itself, and are now searching for a drug to reverse it.

Beta blockers not needed after heart attack if other medications taken

September 18, 2017
A new study from the University of North Carolina at Chapel Hill finds beta blockers are not needed after a heart attack if heart-attack survivors are taking ACE inhibitors and statins. The study is the first to challenge ...

Which single behavior best prevents high blood pressure?

September 15, 2017
(HealthDay)—You probably already know that certain healthy lifestyle behaviors can reduce your risk of developing high blood pressure, but is any one behavior more important than the others?

RESPECT trial shows closing a small hole in heart may protect against recurrent stroke

September 13, 2017
A device used to close a small hole in the heart may benefit certain stroke patients by providing an extra layer of protection for those facing years of ongoing stroke risk, according to the results of a large clinical trial ...

Study shows so-called 'healthy obesity' is harmful to cardiovascular health

September 11, 2017
Clinicians are being warned not to ignore the increased cardiovascular health risks of those who are classed as either 'healthy obese' or deemed to be 'normal weight' but have metabolic abnormalities such as diabetes.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.