Failure to Prescribe Heart Drug Costs Lives, Studies Say

Thousands of lives are being lost each year because doctors fail to prescribe an inexpensive, highly effective family of drugs called beta blockers to patients who have suffered heart attacks, researchers said Tuesday.

In some cases, heart attack victims are not receiving the drugs because the patients have other problems, such as lung disease or diabetes, that doctors had previously thought would be exacerbated by beta blockers.

But half of the patients who are considered ideal candidates for the drugs do not receive them, perhaps because physicians--particularly general practitioners--are not aware of their value or are conservative in their prescribing practices, the research shows.

Two new reports published this week in the Journal of the American Medical Assn. and the New England Journal of Medicine, based on studies of more than 200,000 Medicare recipients, suggest that the vast majority of heart attack victims should be taking beta blockers, which reduce the risk of death by as much as 40% in the first two years of use.

The findings “should change the prescribing practices of physicians,” said Dr. Valentin Fuster, president of the American Heart Assn. and a cardiologist at Mt. Sinai Medical Center in New York City.

About 950,000 Americans survive heart attacks each year and as many as 11 million Americans have a history of heart attacks or angina pectoris.

The beta blockers are a prime example of a medical technology that both saves lives and reduces health care costs, but pharmaceutical companies do not promote them heavily perhaps because they are so cheap--about $5 per month, experts say. Many physicians are thus not aware of their true value.

“Now, our job is to get everybody who can benefit onto the treatment,” said Dr. Rodman Starke, vice president for science and medicine of the American Heart Assn.

Beta blockers work by interfering with the activity of naturally produced hormones such as adrenaline and epinephrine. Those hormones create the “flight or fight” response to stressful or dangerous events. Among other things, the hormones make the heart beat faster and increase blood pressure.

Those are good responses if you are confronted with, say, a bear, Starke said, “but not so good if you have had a heart attack.” By preventing the adrenaline response, beta blockers keep blood pressure and heart rates lower, decreasing the physical exertions that might trigger a second heart attack.

But the drugs have previously been studied primarily in younger people with uncomplicated heart attacks. Intuitively, many physicians have feared that slowing the heart in the elderly or in people with other complications would make their heart problems worse. “This data says that it is not harmful, but is actually helpful,” Starke said.

The first study, led by Dr. Harlan M. Krumholz of Yale University, studied the records of 115,015 elderly Medicare patients who survived a heart attack in 1994 or 1995. All were patients for whom “there was no question that they should get beta blockers,” Krumholz said. Only half received the drugs.

The use of the drugs varied widely from state to state. The highest use was in the New England region, where 72.6% of patients received beta blockers. On the Pacific Coast, including California, 48.2% of patients got them. The lowest rates were in the Midwest and South, with Nevada, Oklahoma, Arkansas and Mississippi coming in around 30%.

Cardiologists and internists, especially those at universities and medical schools, were most likely to prescribe the drugs, while general practitioners were least likely.

Overall, those patients who received beta blockers were 14% less likely to die in the first year after a heart attack.

But Dr. David Faxon of USC, a director of the American Heart Assn.’s Western region, cautioned that the data are three years old and that usage has increased since then. Another recent study with data from the National Heart Attack Registry, he said, showed that use of beta blockers increased 10% last year alone.

In the second study, Dr. Stephen S. Gottlieb and his colleagues at the University of Maryland School of Medicine in Baltimore studied the Medicare records of 201,752 heart attack patients. Many of those were the same patients as in Krumholz’s study, but Gottlieb also included patients that Krumholz excluded because they had such conditions as diabetes, chronic obstructive lung disease, and so-called non-Q-wave heart attacks.

National prescribing guidelines for beta blockers do not recommend treating such patients with the drugs, but do not specifically exclude them. Overall, only 34% of the patients in the study had received beta blockers. But in every subgroup the Maryland team examined, those who received beta blockers had a better chance of survival.

In patients who had had a heart attack but no other complicating factors, use of the drug produced a 40% decrease in deaths over two years. Among diabetic heart attack victims, beta blockers produced a 36% reduction in deaths. The drugs produced a 40% reduction in deaths among those with pulmonary disease, and a similar decrease in patients with congestive heart failure.

Overall, the team concluded, 19,000 patients in the group could have been kept alive if beta blockers had been more widely prescribed.

“This will wake up many people in the system who are not using beta blockers,” Fuster said.

But, Faxon cautioned, “there is no question that some patients shouldn’t get beta blockers,” such as those with very severe heart failure or shock. Patients with asthma can even be damaged by the drugs.

Krumholz also noted in an editorial in the New England Journal that Gottlieb’s group was unable to quantify the seriousness of the complications that were studied. In a patient with mild lung disease, for example, beta blockers might be helpful, but in patients with very severe lung disease, they could be dangerous.

“Clearly, we need a lot more clinical trials” with such disorders, he concluded.

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Beta Blocker Use by State

A heart patient’s chance of receiving beta blockers for prevention of future heart attacks varies greatly across the country, according to a new study. The use of the drugs ranges from 30% of appropriate patients in Mississippi to 77% in Connecticut. In California, the drug is prescribed to about half the patients who should get it, the study says.

Percent of heart patients using beta blockers

66%-77%

Connecticut

Maine

Massachusetts

New Hampshire

Rhode Island

****

53%-67%

Alaska

Delaware

Iowa

Maryland

Michigan

Minnesota

New Jersey

New York

North Dakota

Ohio

Pennsylvania

Vermont

Wisconsin

****

44%-52%

Alabama

California

Colorado

Florida

Georgia

Idaho

Illinois

Indiana

Lousiana

Montana

Nebraska

North Carolina

Oregon

South Carolina

South Dakota

Utah

Virginia

West Virginia

****

39%-43%

Arizona

Hawaii

Kansas

Kentucky

Missouri

New Mexico

Puerto Rico

Tennessee

Texas

Washington

Washington, D.C

Wyoming

****

30%-38%

Arkansas

Mississippi

Nevada

Oklahoma

Source: The Journal of the American Medical Assn.

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