Review
Usefulness of Beta Blockade in Contemporary Management of Patients With Stable Coronary Heart Disease

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Considerable progress has been made over the last few decades in the management of clinically stable coronary heart disease (SCHD), including improvements in interventions (e.g., percutaneous revascularization), pharmacological management, and risk factor control (e.g., smoking, diet, activity level, hypercholesterolemia, hypertension). Although β blockers have long been used for the treatment of SCHD, their efficacy was established in the era before widespread use of reperfusion interventions, modern medical therapy (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers), or preventive treatments (e.g., aspirin, statins). On the basis of these older data, β blockers are assumed beneficial, and their use has been extrapolated beyond patients with heart failure and previous myocardial infarction, which provided the best evidence for efficacy. However, there are no randomized clinical trials demonstrating that β blockers decrease clinical events in patients with SCHD in the modern era. Furthermore, these agents are associated with weight gain, problems with glycemic control, fatigue, and bronchospasm, underscoring the fact that their use is not without risk. In conclusion, data are currently lacking to support the widespread use of β blockers for all SCHD patients, but 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.

Section snippets

Historical Perspective

In the United States, CHD accounts for approximately 1/3 of all deaths.4 CAD pathophysiology is related to the adrenergic nervous system, which consists of 2 major receptor types in the adrenergic system (α and β), and was first described in the mid-20th century.5 Alpha receptor activation is associated with contraction of vascular smooth muscle. Beta receptor activation is associated with stimulation of the heart (β1) and relaxation of vascular smooth muscle, bronchi, and uterus (β2).5 Sir

Changes in Stable CHD Management over Time

There has been a dramatic reduction in CHD since the 1960s in the industrialized countries.4, 12 After peaking in 1964 to 1968, at a rate of >200 deaths per 100,000 people, the CHD death rate in the United States has steadily decreased12 to 135 deaths per 100,000 people in 2006 and an age-adjusted rate of 113 per 100,000 population in 2010 (Figure 1).3 CHD mortality has reduced substantially in many European countries, decreasing by >50% between 1980 and 2009.13 A 2007 analysis of CHD suggested

Limitations and side effects of β blockade

Beta blockers have a number of side effects that may limit their role in contemporary management. Discontinuation rates of β blockers may be as high as 25% within the first year and 50% over longer periods of time.21 High discontinuation rates for β blockers are at least partially attributable to these adverse effects that are disagreeable to patients.

Role of β blockade in contemporary management of SCHD

The contemporary role for β blockers has narrowed as we document their limitations, determine their optimal duration of therapy, and develop other effective interventions. Although the most recent guidelines from the United States and Europe still endorse the use of β blockers in a wide range of patients, they now reflect limitations of the data supporting the use of β blockers in the management of many patient groups. Earlier guidelines from the American Heart Association/American College of

Acknowledgment

Michelle Daniels, MD, of inScience Communications provided medical writing support funded by Gilead Sciences, Inc.

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    The development of this manuscript was supported by Gilead Sciences, Foster City, CA.

    See page 1611 for disclosure information.

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