Beta-blocker use and risk of symptomatic bradyarrhythmias:A hospital-based case-control study

OBJECTIVE: To investigate the risk factors of symptomatic bradyarrhythmias in relation to β-blockers use. METHODS: A hospital-based case-control study [228 patients: 108 with symptomatic bradyarrhythmias (cases) and 120 controls] was conducted in Sultanah Aminah Hospital, Malaysia between January 2011 and January 2014. RESULTS: The mean age was 61.1 ± 13.3 years with a majority of men (68.9%). Cases were likely than control to be older, hypertensive, lower body mass index and concomitant use of rate-controlling drugs (such as digoxin, verapamil, diltiazem, ivabradine or amiodarone). Significantly higher level of serum potassium, urea, creatinine and lower level of estimated glomerular filtration rate (eGFR) were observed among cases as compared to controls. On univariate analysis among patients on β-blockers, older age (crude OR: 1.07; 95% CI: 1.03–1.11, P = 0.000), hypertension (crude OR: 5.6; 95% CI: 1.51–20.72, P = 0.010), lower sodium (crude OR: 0.04; 95% CI: 0.81–0.99, P = 0.036), higher potassium (crude OR: 2.36; 95% CI: 1.31–4.26, P = 0.004) and higher urea (crude OR: 1.23; 95% CI: 1.11–1.38, P = 0.000) were associated with increased risk of symptomatic bradyarrhythmias; eGFR was inversely and significantly associated with symptomatic bradyarrhythmias in both ‘β-blockers’ (crude OR: 0.97; 95% CI: 0.96–0.98, P = 0.000) and ‘non-β-blockers’ (crude OR: 0.99; 95% CI: 0.97–0.99, P = 0.023) arms. However, eGFR was not significantly associated with symptomatic bradyarrhythmias in the final model of both ‘β-blockers’ (adjusted OR: 0.98; 95% CI: 0.96–0.98, P = 0.103) and ‘non-β-blockers’ (adjusted OR: 0.99; 95% CI: 0.97–1.01, P = 0.328) arms. Importantly, older age was a significant predictor of symptomatic bradyarrhythmias in the ‘β-blockers’ as compared to the ‘non-β-blockers’ arms (adjusted OR: 1.09; 95% CI: 1.03–1.15, P = 0.003 vs. adjusted OR: 1.03; 95% CI: 0.98–1.09, P = 0.232, respectively). CONCLUSION: Older age was a significant predictor of symptomatic bradyarrhythmias in patients on β-blockers than those without β-blockers

Are there gender differences in coronary artery disease? The Malaysian National Cardiovascular Disease Database - Percutaneous Coronary Intervention (NCVD-PCI) Registry.

OBJECTIVES: To assess whether gender differences exist in the clinical presentation, angiographic severity, management and outcomes in patients with coronary artery disease (CAD). METHODS: The study comprised of 1,961 women and 8,593 men who underwent percutaneous coronary intervention (PCI) and were included in the Malaysian NCVD-PCI Registry from 2007-2009. Significant stenosis was defined as ≥70% stenosis in at least one of the epicardial vessels. RESULTS: Women were significantly older and had significantly higher rates of diabetes mellitus, hypertension, chronic renal failure, new onset angina and prior history of heart failure whereas smokers and past history of myocardial infarction were higher in men. In the ST-elevation myocardial infarction (STEMI) cohort, more women were in Killip class III-IV, had longer door-to-balloon time (169.5 min. vs 127.3 min, p<0.052) and significantly longer transfer time (300.4 min vs 166.3 min, p<0.039). Overall, women had significantly more left main stem (LMS) disease (1.3% vs 0.6%, p<0.003) and smaller diameter vessels (<3.0 mm: 45.5% vs 34.8%, p<0.001). In-hospital mortality rates for all PCI, STEMI, Non-STEMI (NSTEMI) and unstable angina for women and men were 1.99% vs 0.98%, Odds ratio (OR): 2.06 (95% confidence interval (CI): 1.40 to 3.01), 6.19% vs 2.88%, OR: 2.23 (95% CI: 1.31 to 3.79), 2.90% vs 0.79%, OR: 3.75 (95% CI: 1.58 to 8.90) and 1.79% vs 0.29%, OR: 6.18 (95% CI: 0.56 to 68.83), respectively. Six-month adjusted OR for mortality for all PCI, STEMI and NSTEMI in women were 2.18 (95% CI: 0.97 to 4.90), 2.68 (95% CI: 0.37 to 19.61) and 2.66 (95% CI: 0.73 to 9.69), respectively. CONCLUSIONS: Women who underwent PCI were older with more co-morbidities. In-hospital and six-month mortality for all PCI, STEMI and NSTEMI were higher due largely to significantly more LMS disease, smaller diameter vessels, longer door-to-balloon and transfer time in women

Risk of mortality at 6 months for women compared to men.

<p>Abbreviations: PCI  =  percutaneous coronary intervention; STEMI =  ST- elevation myocardial infarction; NSTEMI =  non-STEMI.</p>*<p>Odds ratio of female vs male and 95% CI obtained through logistic regression including the following covariates: Age, smoking, diabetes, hypertension, new onset of angina, prior history of heart failure, renal failure.</p>†<p>Odds ratio of female vs male and 95% CI obtained through logistic regression including the following covariates: Age, smoking, diabetes, hypertension, new onset of angina, prior history of heart failure, renal failure and Killip class.</p

Prognostic factors for in-hospital mortality by gender

<p>Abbreviations: PCI  =  percutaneous coronary intervention; STEMI =  ST- elevation myocardial infarction; NSTEMI =  non-STEMI.</p

In-patient clinical care by gender.

*<p>patients who underwent PCI as emergent procedure (primary and rescue) during same index admission.</p>†<p>As a percentage of total emergent PCI.</p><p><i>p</i>-values are calculated for gender, comparing all sub-categories except the unknown catergory for all variables.</p><p>All p-values are calculated using the Chi-square test unless stated.</p

Risk of mortality at 30 days for total population.

<p>Abbreviations: PCI  =  percutaneous coronary intervention; STEMI =  ST- elevation myocardial infarction; NSTEMI =  non-STEMI.</p><p>Odds ratio of total mortality and 95% CI obtained through logistic regression including the following covariates: Gender, age, smoking, hypertension, diabetes, prior history of heart failure, new onset of angina, renal failure and Killip class.</p

Risk of mortality at 6 months for total population

<p>Abbreviations: PCI  =  percutaneous coronary intervention; STEMI =  ST- elevation myocardial infarction; NSTEMI =  non-STEMI.</p><p>Odds ratio of total mortality and 95% CI obtained through logistic regression including the following covariates: Gender, age, smoking, hypertension, diabetes, prior history of heart failure, new onset of angina, renal failure and Killip class.</p

Patients’ baseline characteristics and clinical presentation on admission by gender.

<p><i>p</i>-values are calculated for gender, comparing all sub-categories except the unknown category for all variables.</p><p>All p-values are calculated using the Chi-square test unless stated.</p

Risk of mortality at discharge for total population

<p>Abbreviations: PCI  =  percutaneous coronary intervention; STEMI =  ST- elevation myocardial infarction; NSTEMI =  non-STEMI.</p><p>Odds ratio of total mortality and 95% CI obtained through logistic regression including the following covariates: Gender, age, smoking, hypertension, diabetes, prior history of heart failure, new onset of angina, renal failure and Killip class.</p

In hospital mortality for women compared to men.

<p>Abbreviations: PCI  =  percutaneous coronary intervention; STEMI =  ST- elevation myocardial infarction; NSTEMI =  non-STEMI.</p>*<p>Odds ratio of female vs male and 95% CI obtained through logistic regression including the following covariates: Age, smoking, diabetes, hypertension, new onset of angina, prior history of heart failure, renal failure.</p>†<p>Odds ratio of female vs male and 95% CI obtained through logistic regression including the following covariates: Age, smoking, diabetes, hypertension, new onset of angina, prior history of heart failure, renal failure and Killip class.</p