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Drug benefits outweigh risks
It’s no secret beta-blockers are enormously successful in preventing a second heart attack or sudden death.
Or is it?
The American Medical Association (AMA) in Chicago thinks it’s a well-kept secret.
For the first time in its 151-year history, the AMA marshaled its resources and teamed with five other professional associations last December to send out a nationwide alert to 170,000 physicians, recommending the use of beta-blockers for patients who suffered an acute MI.
Beta-blockers already account for 5.5% of prescriptions dispensed in the United States, according to IMS Health, and independent pharmaceutical tracker in Plymouth Meeting, PA. For every 1,000 U.S. HMO members, 192 prescriptions for beta-blockers are written.
Also for the first time, the AMA says the benefits of beta-blockers outweigh the risk for conditions for which the drugs were previously contraindicated.
Departing from a long-standing caveat against prescribing beta-blockers for many patients with asthma, diabetes, obstructive pulmonary disease, severe peripheral vascular disease, PR intervals greater than .24 seconds, and moderate to severe LV failure, the AMA says "there is evidence to suggest that many of these patients will benefit from beta-blocker therapy," but "decisions should be made on a case-by-case basis."
In the past, many physicians believed the contraindications were an "absolute," says Percy Wootton, MD, past president of the AMA and clinical cardiologist practicing in Richmond, VA.
"Beta-blockers can be used safely by many of these patients when closely followed by a physician," Wootton says.
It’s a matter of practice catching up with science, the experts say.
"This is based on scientific knowledge," says Wootton. "We know beta-blockers increase long-term survival up to 40% after acute MIs.
"Cardiovascular disease is still the No. 1 killer of both women and men. Beta-blockers are dirt cheap and just as common as dirt, so our goal is to get people to use them."
"We wanted to bring it to the attention of general practitioners that beta-blocker prophylaxis has an important role for many patients who are post-MI," says Herbert Young, MD, director of the scientific activities division at the American Academy of Family Physicians (AAFP), one of five major medical associations who issued the alert.
"All of us are in agreement," Young says. "The science is good, but the practice needs to be improved."
The scientific community validated the importance of beta-blockers over the decade or more they have been in common use.
"It is an evolutionary process," Young says. "Now the science is solid; we need to get the information to the physicians when they need it."
Why aren’t more physicians already prescribing beta-blockers?
"It’s incredible that family practitioners wouldn’t know about beta-blockers; they’ve been around so long," says Jackie Williamson, MD, a family practitioner in Woodstock, GA.
Williamson suggests there may be other reasons why family practitioners don’t prescribe beta-blockers:
1. Most patients with heart attacks are discharged from the hospital by a cardiologist, and the cardiologist would prescribe the medications. Most family practitioners are reluctant to override the wishes of a specialist.
2. Beta-blockers have been around for a long time, but there are new kids on the block, like ace-inhibitors and calcium channel blockers, that are just as effective and may not have some of the unpleasant side effects of beta-blockers.
3. Side effects are a problem, particularly the sexual dysfunction sometimes connected with the use of beta-blockers, Williamson says. "It may be that some doctors don’t want to use them for that reason or patients won’t take them anyway if sexual dysfunction becomes a problem."
This first Quality Care Alert is seen as only one step in a larger effort to increase physician and patient awareness of the efficacy of beta-blockers.
"It’s a small step in a complex process," Young says. "We need to bring knowledge to people repetitively through a variety of channels. This one mailing isn’t the end-all."
"We’re following the learning model that says you have to tell somebody something three times," Wootton says.
Reminders of the beta-blocker alert will be added "as a postscript" to other alerts in the coming months. An alert on pneumococcal vaccine was planned for late February or early March.
While experts say some patients are not good candidates for beta-blockers, Wootton says primary care physicians need to "use their judgment" to determine the severity of the disease and weigh the risks.
He advises them to monitor patients for a variety of possible complications, including indications of constriction of peripheral arteries or prolonged PR intervals through ECGs and physical monitoring.
The unprecedented year-long collaborative effort between the AMA and the other associations "recognizes that all of medicine has a challenge," says Young. "No specialty is out there where we’d like it to be. Our focus should be on improving care for all patients, not bickering among specialties."
Wootton and his AMA colleagues hope the alert will also encourage patients to ask their doctors about beta-blockers.
"As a physician, I have absolutely no problem with a patient saying, Doctor, shouldn’t I be on beta-blockers?’ I am a firm believer in educating patients," he said.
For more information, Percy Wootton can be reached through the AMA at (312) 464-5000; Herbert Young can be reached through the AAFP at (800) 274-2237.