Ambulatory Care Quarterly
Elderly AMI patients don't always get beta-blockers
Those who need them most are less likely to get them
When elderly patients with acute myocardial infarction (AMI) come to emergency departments (EDs), they are less likely to be given beta-blockers than younger patients, says a new study.
Of 270 patients with ST-elevation myocardial infarction (STEMI) who did not receive beta-blockers, 59% were older than age 60. "Elderly patients with AMI tend to have worse outcomes than younger patients and have the greatest potential for benefit with beta-blockers,"1 says David D. Vega, MD, assistant program director of the emergency medicine residency program at York (PA) Hospital. "These may be the very patients who receive them the least."
Collaborate with physicians to develop educational programs regarding the benefits of beta-blockers for AMI patients, he recommends. "This may help to promote an understanding of the great extent of benefit with these medications, which is often underestimated by practitioners."
Many ED nurses may have misconceptions about the true contraindications to beta-blockers, says Vega. "One of the big misunderstandings regarding the use of beta-blockers is that a history of [congestive heart failure] alone does not preclude their use. They are contraindicated in the setting of an acute exacerbation of CHF." The same criteria apply with chronic obstructive pulmonary disease (COPD) and asthma: Beta-blockers are contraindicated only in patients with acute exacerbations of COPD and asthma, not all patients with a history of these conditions, he adds.
The bradycardia contraindication applies for heart rates below 60 bpm, he adds. "Despite the fears of many providers, patients may still receive beta-blockers with a heart rate in the 60s." Likewise, the hypotension contraindication applies for systolic blood pressures below 100 mmHg, Vega says. "Providers sometimes withhold beta-blockers for systolic blood pressure in the 110s or 120s, but many of these patients can still safely be given the medicine."
Use standing orders or order sets that prompt for the use of beta-blockers in the absence of contraindications, he suggests. At York Hospital's ED, when an AMI patient arrives and the initial care is completed, the nurse or physician pulls the order set as soon as possible. They then consider treatments such as beta-blockers, says Donna Fitz, RN, MS, CEN, SANE-A, clinical nurse specialist for the ED. "The contraindications are discussed with the physician," she says.
ED nurses were notified of the study's findings via e-mail to raise awareness about patients at risk for not receiving beta-blockers, says Fitz. "This is getting more attention in our ED," she says. "We are educating our nurses by informal discussion with physicians, which increases the frequency of the use of beta-blockers."
- Vega DD, Dolan KL, Pollack ML. b-Blocker use in elderly ED patients with acute myocardial infarction. Presented at the Society for Academic Emergency Medicine's New York State Regional Meeting. New York City; March 31, 2004.