Statin and ß-Blocker Therapy and the Initial Presentation of Coronary Heart Disease

21 February 2006 | Volume 144 Issue 4 | Pages 229-238

Background: Coronary atherosclerosis develops slowly over decades but is frequently characterized clinically by sudden unstable episodes. Patients who present with unstable coronary disease, such as acute myocardial infarction, may systematically differ from patients who present with relatively stable coronary disease, such as exertional angina.

Objective: To examine whether medication use or patient characteristics influence the mode of initial clinical presentation of coronary disease.

Design: Case–control study.

Setting: Large integrated health care delivery system in northern California.

Patients: Adults whose first clinical presentation of coronary disease was either acute myocardial infarction (n = 916) or stable exertional angina (n = 468).

Measurements: Use of cardiac medications before the event from pharmacy databases and demographic, lifestyle, and clinical characteristics from self-report and clinical and administrative databases.

Results: Compared with patients with incident stable exertional angina, patients with incident acute myocardial infarction were more likely to be men, smokers, physically inactive, and hypertensive but were less likely to have a parental history of coronary disease. Patients presenting with myocardial infarction were much less likely to have received statins (19.3% vs. 40.4%; P < 0.001) and ß-blockers (19.0% vs. 47.7%; P < 0.001) than patients presenting with exertional angina. After adjustment for potential confounders, recent use of statins (adjusted odds ratio, 0.45 [95% CI, 0.32 to 0.62]) and ß-blockers (adjusted odds ratio, 0.26 [CI, 0.19 to 0.35]) was associated with lower likelihoods of presenting with an acute myocardial infarction than with stable angina.

Limitations: This observational study did not have information on all possible confounding factors, including use of aspirin therapy.

Conclusion: Statin and ß-blocker use was associated with lower odds of presenting with an acute myocardial infarction than with stable angina. Additional studies are needed to confirm that these therapies protect against unstable, higher-risk clinical presentations of coronary disease.

Editors' Notes Context We know little about factors that are associated with initial clinical presentations of coronary disease. Contribution This large case–control study compared characteristics of patients whose first clinical presentation of coronary disease was either acute myocardial infarction or stable exertional angina. Patients presenting with myocardial infarction rather than stable angina had received statins and ß-blockers less often; were more often men, smokers, and physically inactive; and more often had hypertension and diabetes. Cautions The study was observational and could not prove cause and effect. Implications Several factors, including statin and ß-blocker therapy, might protect against higher-risk presentations of coronary disease. —The Editors

 

Author and Article Information

From Kaiser Permanente of Northern California, Oakland, California; University of California, San Francisco, San Francisco, California; and Stanford University School of Medicine, Stanford, California.

Grant Support: By the Donald W. Reynolds Foundation, Las Vegas, Nevada.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Alan S. Go, MD, Division of Research, Kaiser Permanente of Northern California, 2000 Broadway Street, 3rd Floor, Oakland, CA 94612-2304; e-mail, Alan.S.Go{at}kp.org.

Current Author Addresses: Drs. Go and Iribarren, Ms. Chandra, and Mr. Lathon: Division of Research, Kaiser Permanente of Northern California, 2000 Broadway Street, 3rd Floor, Oakland, CA 94612-2304.

Dr. Fortmann: Stanford Medical School, Hoover Pavillion, MD 5705, Stanford, CA 94305-5705.

Dr. Quertermous: Stanford University, Falk Building, 300 Pasteur Drive, Stanford, CA 94305.

Dr. Hlatky: Stanford University, HRP Redwood Building, Room 150, Stanford, CA 94305.

Author Contributions: Conception and design: A.S. Go, C. Iribarren, M. Chandra, S.P. Fortmann, T. Quertermous, M.A. Hlatky.

Analysis and interpretation of the data: A.S. Go, C. Iribarren, M. Chandra, P.V. Lathon, S.P. Fortmann, M.A. Hlatky.

Drafting of the article: A.S. Go, M. Chandra, M.A. Hlatky.

Critical revision of the article for important intellectual content: A.S. Go, C. Iribarren, M. Chandra, P.V. Lathon, S.P. Fortmann, T. Quertermous, M.A. Hlatky.

Final approval of the article: A.S. Go, C. Iribarren, M. Chandra, P.V. Lathon, S.P. Fortmann, T. Quertermous, M.A. Hlatky.

Provision of study materials or patients: A.S. Go.

Statistical expertise: A.S. Go, M. Chandra, M.A. Hlatky.

Obtaining of funding: A.S. Go, C. Iribarren, S.P. Fortmann, T. Quertermous, M.A. Hlatky.

Administrative, technical, or logistic support: A.S. Go, M. Chandra, P.V. Lathon, T. Quertermous, M.A. Hlatky.

Collection and assembly of data: A.S. Go, C. Iribarren, M. Chandra, P.V. Lathon, M.A. Hlatky.