Faculty Bibliography

BACKGROUND: In patients with prior myocardial infarction (MI), beta-blockers reduce mortality by 23% to 40%. However, despite this favorable effect, adverse effects limit compliance to this medication. The purpose of the study was to compare a beta-blocker-based strategy with a heart rate-lowering calcium antagonists-based strategy in patients with prior MI. METHODS: We evaluated 7,218 patients with prior MI enrolled in the INternational VErapamil SR-Trandolapril (INVEST) substudy randomized to verapamil-sustained release (SR)- or atenolol-based strategies. Primary outcome was time to first occurrence of death (all-cause), nonfatal MI, or nonfatal stroke. Secondary outcomes included death, total MI (fatal and nonfatal), and total stroke (fatal and nonfatal) considered separately. RESULTS: During the 2.8 +/- 1.0 years of follow-up, patients assigned to the verapamil-SR-based and atenolol-based strategies had comparable blood pressure control, and the incidence of the primary outcome was equivalent. There was no difference between the 2 strategies for the outcomes of either death or total MI. However, more patients reported excellent/good well-being (82.3% vs 78.0%, P = .02) at 24 months with a trend toward less incidence of angina pectoris (12.0% vs 14.3%, adjusted P = .07), nonfatal stroke (1.4% vs 2.0%; P = .06), and total stroke (2.0% vs 2.5%, P = .18) in the verapamil-SR-based strategy group. CONCLUSIONS: In hypertensive patients with prior MI, a verapamil-SR-based strategy was equivalent to a beta-blocker-based strategy for blood pressure control and prevention of cardiovascular events, with greater subjective feeling of well-being and a trend toward lower incidence of angina pectoris and stroke in the verapamil-SR-based group

OBJECTIVES: This study sought to evaluate the efficacy of beta-blockers (BBs) for primary prevention of heart failure (HF) in patients with hypertension. BACKGROUND: The American College of Cardiology/American Heart Association staging for HF classifies patients with hypertension as stage A HF, for which BBs are a treatment option. However, the evidence to support this is unknown. METHODS: We conducted a MEDLINE/EMBASE/CENTRAL search of randomized controlled trials that evaluated BB as first-line therapy for hypertension with follow-up for at least 1 year and with data on new-onset HF. The primary outcome was new-onset HF. Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. RESULTS: Among the 12 randomized controlled trials, which evaluated 112,177 patients with hypertension, BBs reduced blood pressure by 12.6/6.1 mm Hg when compared with placebo, resulting in a 23% (trend) reduction in HF risk (p = 0.055). When compared with other agents, the antihypertensive efficacy of BBs was comparable, which resulted in similar but no incremental benefit for HF risk reduction in the overall cohort (risk ratio: 1.00; 95% confidence interval: 0.92 to 1.08), in the elderly (> or =60 years) or in the young (<60 years). Analyses of secondary outcomes showed that BBs confirmed similar but no incremental benefit for the outcomes of all-cause mortality, cardiovascular mortality, and myocardial infarction but increased stroke risk by 19% in the elderly. CONCLUSIONS: In hypertensive patients, primary prevention of HF is strongly dependent on blood pressure reduction. When compared with other antihypertensive agents, there was similar but no incremental benefit of BBs for the prevention of HF. However, given the increased risk of stroke in the elderly, BBs should not be considered as first-line agents for prevention of HF