Most Stable Heart Patients Do Not Need Beta-Blockers

Taking beta-blockers—a common drug regimen for patients with clinically stable coronary heart disease (SCHD)—likely does not have a benefit or outweigh these drugs’ risk for most SCHD patients, a University of Florida team reports.

Writing online in the American Journal of Cardiology David Winchester MD,MS and Carl Pepine MD of the Division of Cardiovascular Medicine at the University of Florida College of Medicine, argue for discontinuing these drugs for most SCHD patients. The use of these drugs is outmoded and never shown in a randomized clinical trial to work to ward off serious cardiac events, they said.

"I see this on a daily basis," Winchester said in an interview, "The assumption seems to be these patients have to be on a beta-blocker for life."

Beta-blockers expose these patients to potential weight gain, problems with glycemic control, fatigue, and bronchospasm.

They have also been shown to cause a rise in development of new diabetes, depression, sexual dysfunction. For all those reasons, about 25% SCHD patients taking beta blocks stop doing so within a year, the authors found. Over longer periods, as many as 50% discontinue the drugs.

Winchester and Pepine write that the drugs’ efficacy was established in an era before there was widespread use of reperfusion interventions, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, statins or even routine use of aspirin.

“On the basis of these older data, beta-blockers are assumed beneficial and their use has been extrapolated beyond patients with heart failure and previous myocardial infarction—where there is good evidence of efficacy.”

But there have been no randomized clinical trials demonstrating that beta-blockers decrease clinical events in patients with SCHD in the modern era.

“Contemporary data suggest that they be reserved for a well defined high-risk group of patients with evidence of ongoing ischemia, left ventricular dysfunction, heart failure, and perhaps some arrhythmias,” they conclude.

In fact, they said, the lack of proof of efficacy of beta-blockers for SCHD is noted in the most recent European Society of Cardiology Guidelines.

The American Heart Association/American College of Cardiology 2012 guidelines for these patients has only a class IIb, level of evidence C recommendation.

The researchers argue for putting most SCHD patients on a regimen of other anti-angina drugs, without beta-blockers potential harmful effects.

“It is appropriate to reserve these agents for patients and situations in which benefits outweigh the risks of therapy,” they conclude.

For the rest, Winchester said in the interview, physicians may be pleased to be able to tell a patient he or she can discontinue the drug.

"It's a nice thing to be able to take a patient off a drug," he said.