Abstract
Patients with diabetes mellitus and cardiovascular disease have a high risk of mortality and/or recurrent cardiovascular events. Hypertension control is critical for secondary prevention of cardiovascular events. The objective was to determine rates and predictors of achieving hypertension control among Medicare patients with diabetes and uncontrolled hypertension after hospital discharge for an initial cardiac event. A retrospective analysis of linked electronic health record and Medicare data was performed. The primary outcome was hypertension control within 1 year after hospital discharge for an initial cardiac event. Cox proportional hazard models assessed sociodemographics, medications, utilization, and comorbidities as predictors of control. Medicare patients with diabetes were more likely to achieve hypertension control when prescribed beta‐blockers at discharge or with a history of more specialty visits. Adults ≥ 80 were more likely to achieve control with diuretics. These findings demonstrate the importance of implementing guideline‐directed multidisciplinary care in this complex and high‐risk population.
Keywords: clinical management of high blood pressure (HBP), coronary disease, diabetes, hypertension in the elderly
1. INTRODUCTION
Diabetes mellitus significantly increases an individual's risk of cardiovascular morbidity and mortality.1 After an initial cardiovascular event, the rate of developing congestive heart failure and having a recurrent myocardial infarction is approximately 26% higher among patients with diabetes than among patients without diabetes.1 Furthermore, the short‐term (28‐day) and 1‐year mortality rates after an initial myocardial infarction are significantly higher for men and women with diabetes than for populations without diabetes.2 The long‐term (5‐year) mortality rate is approximately 50% higher for men and women with diabetes than for those without diabetes.3
In the United States, 71% of patients with diabetes also have hypertension. Unfortunately, the majority of patients with diabetes have uncontrolled hypertension even at the higher treatment threshold of < 140/90 mm Hg.4, 5 Therefore, the timely control of hypertension is critical after a myocardial infarction among patients with diabetes. Blood pressure control reduces recurrent major adverse cardiovascular events and cardiovascular mortality in patients with diabetes.6 These benefits are independent of the cardioprotective benefits of medication (eg, beta‐blockers and angiotensin‐converting enzyme inhibitors).6 In addition, aggressive hypertension management reduces cost of complications and increases the time interval without complications in patients with hypertension and diabetes.7 Although glycemic control reduces microvascular complications of diabetes, it lacks an established benefit in reducing cardiovascular events.1, 8
Despite the known adverse events related to hypertension in patients with diabetes, the rate and predictors of hypertension control among patients with diabetes after an initial cardiovascular event are unknown.9 A recent retrospective analysis demonstrated that diabetes was independently associated with unfavorable blood pressure control after a coronary event.10 Therefore, hypertension control should be an integral focus in primary and secondary cardiovascular preventive care in patients with diabetes. Thus, the purpose of our study was to determine predictors of hypertension control among Medicare patients with diabetes mellitus within 1 year following an initial cardiac event. Patients with diabetes and a prior myocardial infarction experience higher rates of recurrent cardiovascular events11 and higher risk of cardiovascular death,11 demonstrating a critical need to achieve hypertension control in this population.
2. RESEARCH DESIGN AND METHODS
2.1. Ethics
The Health Sciences Institutional Review Board at the University of Wisconsin‐Madison approved this study with a waiver of Health Insurance Portability and Accountability Act (HIPAA) authorization.
2.2. Data sources
The data for this study included 2003‐2011 Medicare fee‐for‐service medical claims (Parts A and B), enrollment data from the Centers for Medicare and Medicaid Services (CMS), and clinical data from a provider group's electronic health record (EHR) system. In the United States, Medicare Part A reflects hospital (inpatient) care. Although not part of this analysis, Part A also reflects home health and hospice care. Medicare Part B reflects outpatient and ambulatory care. Medicare enrollment files provided information on demographics, monthly enrollment status, date of death, and third‐party payers. Medical claims provided information on services and procedures performed, including diagnosis codes; enrollment data were linked to the EHR via the patients’ Health Insurance Claims (HIC) numbers using a crosswalk from the provider group. The multispecialty provider group is a large Midwestern academic medical institution. It is both a major source of primary care for the local area and a statewide specialty referral center.
2.3. Sample
Patients were eligible for the study if they had Medicare Parts A and B coverage at least 3 years before cohort entry and were at least 68 years of age. The eligible baseline age started at 68 years old to allow for 3 years of baseline Medicare data to assess inclusion and exclusion criteria prior to cohort entry. Eligible patients also had a baseline diagnosis of diabetes mellitus, uncontrolled hypertension (≥ 140/90 mm Hg if 68‐79 years old and ≥ 150/90 mm Hg if ≥ 80 years old), and an initial cardiac event. Thresholds for uncontrolled hypertension by age group were designed a priori, reflecting the hypertension guidelines during the study period that supported higher treatment goals if ≥ 60 years old.12 Patients entered the study on the date of discharge of their first cardiac event. Eligible cardiac events were identified using International Statistical Classification of Diseases and Related Health Problems (ICD‐9), Current Procedural Terminology (CPT), Diagnosis Related Group (DRG), and Healthcare Common Procedure Coding Systems (HCPCS) codes during the index hospitalization. Eligible diagnoses and procedures included an acute myocardial infarction and/or related cardiac procedure including percutaneous coronary intervention (PCI) with angioplasty ±stent placement of at least 1 coronary vessel, and/or coronary artery bypass grafting (CABG); see supporting information. The first 3 years of study data were analyzed to ensure that all acute cardiac events were a patient's first such event. To identify patients with diabetes mellitus, we used a validated algorithm13 requiring patients to have at least 1 inpatient or skilled nursing facility (SNF) claim or more than 1 professional services claim associated with an International Classification of Diseases, 9th Revision, Clinical Modification (ICD‐9‐CM) code of 250.xx, 357.2, 362.0x, or 366.41 in a 2‐year period. Patients with prevalent hypertension were identified using the validated Tu criteria: 401.x (essential hypertension), 402.x (hypertensive heart disease), 403.x (hypertensive renal disease), 404.x (hypertensive heart and renal disease), and 405.x (secondary hypertension).14, 15
Eligible patients were managed (“medically homed”) by the multispecialty provider group. Two established approaches using patients’ face‐to‐face outpatient evaluation and management (E&M) visits were applied to determine whether patients were managed by the provider group. The “plurality provider algorithm”16, 17 assigns patients to the group accounting for the greatest number of E&M visits in a given year. The “Diabetes Care Home” method considers patients with diabetes to be managed by a provider group in a given year if they had ≥ 2 E&M visits to a primary care provider (PCP), or 1 visit to a PCP and 1 visit to an endocrinologist, over the current and prior years.18 Patients were included if they met either or both of these criteria.
Patients were excluded from the study cohort if they had Medicare railroad benefits, died during the qualifying cardiac event admission, did not have outpatient/ambulatory blood pressures within 90 days after hospital discharge, and/or were enrolled in hospice at baseline or at hospital discharge.
2.4. Dependent outcome
The dependent outcome was achievement of hypertension control within 1 year (12 months) after hospital discharge for an initial cardiac event. Patients were followed from the date they were discharged after a cardiac event (cohort entry date) to the date they achieved hypertension control, were censored, or the study ended. This primary outcome was defined as the first of 2 consecutive clinic visits with blood pressures of < 140/90 mm Hg for 68‐79 year‐olds or < 150/90 mm Hg if ≥ 80 years old to reflect hypertension guidelines during the analysis period.12, 19, 20 Blood pressures were acquired from the EHR of the healthcare system, reflecting seated and attended blood pressures; however, the number of blood pressures obtained during ambulatory visits varied across clinics. Patients were censored after achieving the primary outcome. In a sensitivity analysis, we analyzed differences in predictors using 2 versus 3 consecutive clinic visits at target blood pressures to define hypertension control. Follow‐up was a maximum of 1 year; patients were censored thereafter. Patients were also censored at day of death after discharge, at the end of enrollment in Medicare Parts A and B, or at the end of being medically homed.14, 18, 21
3. EXPLANATORY VARIABLES
3.1. Time invariant covariates
Baseline patient age was divided into 2 categories, 68‐79 years old and ≥ 80 years old, to reflect age differences in US hypertension guideline targets.12 Additional baseline demographics included gender, race/ethnicity, marital status, tobacco use, body mass index (BMI), and the number of ambulatory visits in the baseline period to primary and specialty care. We created variables indicating the presence of comorbidities and/or complications common with diabetes. We used the condition indicators in the Chronic Conditions Summary file during the patient's baseline years to classify the presence of hyperlipidemia, anxiety and/or depression, dementia,22, 23 stroke and/or transient ischemic attack, congestive heart failure (CHF), chronic kidney disease,24 chronic obstructive pulmonary disease (COPD), atrial fibrillation, valvular heart disease, and solid organ malignancy. Validated algorithms were also used to determine the presence of peripheral vascular disease and diabetes complications of peripheral neuropathy and/or retinopathy.25
We used baseline enrollment year claims to calculate the Hierarchical Condition Categories (HCC) community risk score, an established measure of predicted future healthcare utilization based on all diagnoses recorded in professional services/carrier and inpatient/outpatient facility claims.26 We chose the HCC score for risk adjustment over the Charlson27, 28, 29 or Elixhauser30 comorbidity measures because of its inclusion of the full spectrum of diagnoses rather than a select group and evidence of stronger ability to predict mortality.31 Finally, the Medicaid state buy‐in indicator was a proxy for patient income.
3.2. Time‐varying covariates
The total number of unique classes of blood pressure medication was acquired at baseline and at hospital discharge from prescription medication orders within the electronic health record. Indicator variables (presence/absence) were created for each of the following five therapeutic classes: diuretics (including thiazide, loop, potassium‐sparing [ie, aldosterone inhibitors]), angiotensin‐converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists, beta‐blockers, calcium channel blockers, or a merged category of central acting agents/adrenergics/vasodilators (given lower frequency).
3.3. Statistical analysis
Analyses were conducted using SAS 9.4 (SAS Institute, Inc., Cary, NC) and Stata/MP 13 (Stata‐Corp, College Station, TX). Multivariate Cox proportional hazards regression analyses were conducted with robust estimates of the variance to obtain adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs). Unadjusted and adjusted hazard ratios were obtained for each of the 5 antihypertensive therapeutic classes to assess the impact of antihypertensive medication on achieving hypertension control within 1 year after discharge for an acute cardiac event. Hazard ratios were obtained for the entire sample and stratified by age (68‐79 years old; ≥ 80 years old) to reflect hypertension guidelines.12 Antihypertensive therapeutic classes were modeled as primary explanatory variables as indicators of the presence/absence of each class. Additional variables included patient sociodemographic and comorbidity variables and provider characteristics. In sensitivity analyses, groups of the 5 most common medication combinations were constructed; hazard ratios were obtained for each medication combination. Additionally, interaction terms between the individual medication therapeutic classes and age strata were analyzed in separate adjusted models; hazard ratios were obtained via linear combinations of the main effect and interaction term.
4. RESULTS
4.1. Sample characteristics
The final sample included 343 eligible patients with diabetes and uncontrolled hypertension, receiving the majority of their diabetes care with the academic institution (Table 1). At baseline, the younger group (68‐79 years old) was more likely to be male, married, obese (BMI ≥ 30 kg/m2), and current tobacco users. Among comorbid conditions, 68‐79 year‐olds were more likely to be diagnosed with hyperlipidemia, but the ≥ 80‐year‐old group was more likely to be diagnosed with dementia, congestive heart failure, or atrial fibrillation. Prior to admission, there was not a significant difference between age groups and the use of first‐ and second‐line antihypertensive medications20 (ie, diuretics, ACE‐inhibitors/angiotensin II receptor antagonists, beta‐blockers, or calcium channel blockers). Before and after the cardiac event, 68‐79 year‐olds were more likely to be prescribed central acting agents/adrenergic/vasodilators; at discharge, this younger group was also more likely to receive calcium channel blockers. On average, all patients were more likely to have 1 additional medication class added to their antihypertensive regimen.
Table 1.
Baseline demographics of adults with diabetes mellitus and hypertension discharged after an initial acute cardiac event (n = 343)
| By age group | ||||
|---|---|---|---|---|
| Total population n = 343 | 68‐79 years old n = 194 (57%) | ≥ 80 years old n = 149 (43%) | P value | |
| Patient characteristics | ||||
| Age, years, m (SD) | 79 (7.0) | 73 (3.5) | 85 (4.0) | < .001 |
| Female, n (%) | 165 (48) | 82 (42) | 83 (56) | .014 |
| Race/ethnicity, n (%) | ||||
| White | 327 (95) | 181 (93) | 146 (98) | .041 |
| Marital status, n (%) | ||||
| Married/partnered | 167 (49) | 107 (55) | 60 (40) | .006 |
| CMS hierarchical condition categories (HCC) score, m (SD) | 1.9 (1.3) | 1.8 (1.4) | 2.0 (1.1) | .27 |
| Medicaid Buy‐In, m (SD) | 32 (9.3) | 20 (10) | 12 (8.1) | .48 |
| Tobacco use, n (%) | ||||
| Never | 141 (41) | 69 (36) | 72 (48) | .003 |
| Former | 159 (46) | 91 (47) | 68 (46) | |
| Current | 42 (12) | 33 (17) | 9 (6.0) | |
| Body mass index (BMI), kg/m2, m (SD) | 30 (6.0) | 32 (6.3) | 28 (4.8) | < .001 |
| Tertiles of systolic blood pressure at baseline, n (%) | ||||
| ≤ 124 mm Hg | 115 (34) | 62 (32) | 53 (36) | .29 |
| 125‐140 mm Hg | 117 (34) | 73 (38) | 44 (30) | |
| ≥ 141 mm Hg | 111 (32) | 59 (30) | 52 (35) | |
| Baseline comorbid conditions, n (%) | ||||
| Hyperlipidemia | 308 (90) | 184 (95) | 124 (83) | < .001 |
| Anxiety and/or depression | 148 (43) | 82 (42) | 66 (44) | .71 |
| Dementia | 39 (11) | 11 (5.7) | 28 (19) | < .001 |
| Stroke/transient ischemic attack | 37 (11) | 17 (8.8) | 20 (13) | .17 |
| Congestive heart failure | 163 (48) | 78 (40) | 85 (57) | .002 |
| Chronic kidney disease | 142 (41) | 77 (40) | 65 (44) | .46 |
| Peripheral vascular disease | 195 (57) | 102 (53) | 93 (62) | .07 |
| Any diabetes complications (peripheral neuropathy and/or retinopathy) | 120 (35) | 65 (34) | 55 (37) | .51 |
| Chronic obstructive pulmonary disease | 127 (37) | 75 (39) | 52 (35) | .48 |
| Atrial fibrillation | 81 (24) | 38 (20) | 43 (29) | .045 |
| Valvular disease | 81 (24) | 39 (20) | 42 (28) | .08 |
| Solid organ malignancy | 41 (12) | 27 (14) | 14 (9.4) | .20 |
| Baseline blood pressure medications by class, n (%) | ||||
| Diuretics (including potassium‐sparing/aldosterone inhibitors) | 214 (62) | 119 (61) | 95 (64) | .65 |
| ACE‐inhibitors or angiotensin II receptor antagonists | 219 (64) | 129 (66) | 90 (60) | .24 |
| Beta‐blockers | 190 (55) | 104 (53) | 86 (58) | .45 |
| Calcium channel blockers | 110 (32) | 67 (35) | 43 (29) | .26 |
| Central acting/adrenergics & others | 51 (15) | 37 (19) | 14 (9.4) | .013 |
| Total number of blood pressure medications at baseline, m (SD) | 2.1 (1.1) | 2.2 (1.2) | 2.1 (1.1) | .45 |
| Discharge blood pressure medications by class, n (%) | ||||
| Diuretics (including potassium‐sparing/aldosterone inhibitors) | 279 (81) | 159 (82) | 120 (81) | .74 |
| ACE‐inhibitors or angiotensin II receptor antagonists | 283 (83) | 163 (84) | 120 (81) | .40 |
| Beta‐blockers | 310 (90) | 175 (90) | 135 (91) | .90 |
| Calcium channel blockers | 160 (47) | 102 (53) | 58 (39) | .012 |
| Central acting/adrenergics & others | 87 (25) | 59 (30) | 28 (19) | .014 |
| Total number of blood pressure medications at discharge, m (SD) | 3.4 (1.1) | 3.5 (1.1) | 3.2 (1.1) | .003 |
| Ambulatory visits in baseline period, m (SD) | ||||
| Primary care | 5.2 (3.4) | 5.2 (3.6) | 5.1 (3.1) | .77 |
| Specialty care | 3.3 (3.8) | 3.6 (4.2) | 3.0 (3.2) | .12 |
%, percent; BMI, body mass index; kg/m2, kilograms per meters squared; m, mean; mm Hg, millimeters Mercury; n, number; SD, standard deviation. Bold value represents the significant at P < .05.
4.2. Predictors of hypertension control
Overall, 76% (259/343) achieved hypertension control within 1 year after discharge. Table 2 demonstrates unadjusted and adjusted HRs and 95% CIs of predictors of achieving hypertension control after discharge for an initial cardiac event among all adults (≥ 68 years old) with diabetes mellitus. After adjustment for patient sociodemographics, comorbid conditions, and medical utilization, all Medicare recipients were more likely to achieve hypertension control when prescribed beta‐blockers (1.80; 1.08‐3.00) at discharge. At discharge, 90% of patients (n = 310) were prescribed beta‐blockers compared to baseline (55%; n = 190). Among all predictors, a history of more specialty care visits at baseline (HR: 1.07; 1.04‐1.11) was also associated with higher rates of hypertension control. Reasons for censoring included death (n = 89; 26%), end of Medicare coverage (n = 14; 4.1%), end of being medically homed (n = 40; 12%), and end of study/end of data (n = 200; 58%). Death during the study was not statistically associated with any of the 5 antihypertensive therapeutic classes.
Table 2.
Unadjusted and adjusted hazard ratios and 95% CIs of predictors of achieving hypertension control (< 140/90 mm Hg) after an acute cardiac event among adult Medicare recipients with diabetes mellitus (n = 343)
| Variable | Unadjusted HR (95% CI) | P value | Adjusted HR (95% CI) | P value |
|---|---|---|---|---|
| Blood pressure medications by class | ||||
| Diuretics (including potassium‐sparing/aldosterone inhibitors) | 1.06 (0.77‐1.46) | .71 | 1.14 (0.78‐1.67) | .494 |
| ACE‐inhibitors or angiotensin II receptor antagonists | 1.17 (0.84‐1.64) | .35 | 1.18 (0.81‐1.73) | .393 |
| Beta‐blockers | 1.58 (0.99‐2.52) | .056 | 1.80 (1.08‐3.00) | .024 |
| Calcium channel blockers | 1.19 (0.93‐1.52) | .17 | 0.97 (0.73‐1.30) | .847 |
| Central acting/adrenergics & others | 1.37 (1.04‐1.79) | .024 | 1.17 (0.84‐1.65) | .358 |
| Age | ||||
| 68‐79 (reference) | 1.00 | ‐ | 1.00 | ‐ |
| ≥ 80 | 0.87 (0.68‐1.11) | .26 | 1.10 (0.80‐1.51) | .56 |
| Female | 0.82 (0.64‐1.05) | .11 | 0.91 (0.67‐1.26) | .58 |
| Race/ethnicity | ||||
| White (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Nonwhite | 0.95 (0.50‐1.78) | .86 | 1.02 (0.50‐2.08) | .95 |
| Marital status | ||||
| Married/partnered (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Not married | 0.78 (0.61‐0.999) | .049 | 0.81 (0.58‐1.13) | .22 |
| CMS hierarchical condition categories (HCC) score | 1.02 (0.91‐1.13) | .77 | 0.88 (0.74‐1.06) | .17 |
| Medicaid Buy‐In | 0.93 (0.61‐1.43) | .74 | 1.42 (0.83‐2.44) | .20 |
| Tobacco use | .67 | .62 | ||
| Never (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Former | 1.08 (0.83‐1.40) | 1.14 (0.84‐1.54) | ||
| Current | 0.91 (0.60‐1.38) | 0.97 (0.60‐1.55) | ||
| Body mass index (BMI), kg/m2 | 0.999 (0.98‐1.02) | .90 | 1.00 (0.98‐1.03) | .91 |
| Tertiles of systolic blood pressure at baseline | .02 | .16 | ||
| ≤ 124 mm Hg (reference) | 1.00 | ‐ | 1.00 | ‐ |
| 125‐140 mm Hg | 0.83 (0.62‐1.11) | 0.82 (0.59‐1.13) | ||
| ≥ 141 mm Hg | 0.65 (0.48‐0.88) | 0.72 (0.51‐1.01) | ||
| Baseline comorbid conditions | ||||
| Hyperlipidemia | 1.24 (0.82‐1.88) | .30 | 1.27 (0.76‐2.11) | .37 |
| Anxiety and/or depression | 1.14 (0.89‐1.46) | .31 | 1.33 (0.98‐1.80) | .07 |
| Dementia | 1.08 (0.71‐1.64) | .71 | 1.32 (0.80‐2.19) | .28 |
| Stroke/transient ischemic attack | 0.77 (0.51‐1.17) | .23 | 0.66 (0.42‐1.05) | .08 |
| Congestive heart failure | 0.90 (0.70‐1.15) | .39 | 0.88 (0.63‐1.23) | .46 |
| Chronic kidney disease | 1.17 (0.91‐1.50) | .22 | 1.30 (0.92‐1.83) | .13 |
| Peripheral vascular disease | 0.84 (0.66‐1.07) | .16 | 0.81 (0.60‐1.09) | .16 |
| Any diabetes complications (peripheral neuropathy and/or retinopathy) | 1.10 (0.85‐1.43) | .45 | 1.02 (0.75‐1.39) | .88 |
| Chronic obstructive pulmonary disease (COPD)/pulmonary disease | 0.81 (0.63‐1.04) | .10 | 0.96 (0.70‐1.31) | .78 |
| Atrial fibrillation | 0.90 (0.67‐1.21) | .50 | 1.11 (0.78‐1.58) | .57 |
| Valvular heart disease | 0.97 (0.73‐1.30) | .86 | 1.07 (0.76‐1.50) | .71 |
| Solid organ malignancy | 1.21 (0.84‐1.75) | .30 | 1.02 (0.66‐1.56) | .93 |
| Ambulatory visits in baseline period | ||||
| Primary care | 1.03 (0.99‐1.06) | .15 | 1.01 (0.96‐1.05) | .72 |
| Specialty care | 1.08 (1.05‐1.10) | < .001 | 1.07 (1.04‐1.11) | < .001 |
BMI, body mass index; CI, confidence interval; HR, hazard ratio; kg/m2, kilograms per meters squared; mm Hg, millimeters Mercury; n, number. Bold value represents the significant at P < .05.
In analyses stratified by age, among 68‐79 year‐olds (Table 3), none of the antihypertensive medication classes remained independently significant for achieving hypertension control after an initial cardiac event. However, specialty visits remained a significant predictor of achieving hypertension control (HR: 1.08; 1.04‐1.13). Table 4 demonstrates that ≥ 80‐year‐olds were more likely to achieve control with diuretics (HR: 3.03; 1.40‐6.57) and beta‐blockers (HR: 4.78; 1.54‐14.85). Nonwhite older adults were also more likely to achieve hypertension control (HR: 7.48; 1.02‐54.77).
Table 3.
Unadjusted and adjusted hazard ratios and 95% CIs of independent predictors of achieving hypertension control (< 140/90 mm Hg) after an acute cardiac event among adults 68‐79 years old with diabetes mellitus (n = 194)
| Variable | Unadjusted HR (95% CI) | P value | Adjusted HR (95% CI) | P value |
|---|---|---|---|---|
| Blood pressure medications by class | ||||
| Diuretics (including potassium‐sparing/aldosterone inhibitors) | 0.73 (0.49‐1.09) | .12 | 0.64 (0.38‐1.08) | .09 |
| ACE‐inhibitors or angiotensin II receptor antagonists | 1.12 (0.72‐1.73) | .62 | 1.43 (0.86‐2.36) | .17 |
| Beta‐blockers | 0.99 (0.58‐1.69) | .98 | 1.64 (0.88‐3.07) | .12 |
| Calcium channel blockers | 1.10 (0.80‐1.50) | .56 | 1.03 (0.70‐1.53) | .88 |
| Central acting/adrenergics & others | 1.26 (0.90‐1.76) | .18 | 1.09 (0.71‐1.66) | .70 |
| Female | 0.85 (0.62‐1.17) | .32 | 0.93 (0.61‐1.44) | .75 |
| Race/ethnicity | ||||
| White (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Nonwhite | 0.65 (0.30‐1.39) | .27 | 0.85 (0.36‐2.05) | .72 |
| Marital status | ||||
| Married/partnered (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Not married | 0.80 (0.58‐1.11) | .18 | 0.82 (0.53‐1.29) | .40 |
| CMS hierarchical condition categories (HCC) score | 1.01 (0.90‐1.14) | .88 | 0.97 (0.77‐1.23) | .82 |
| Medicaid Buy‐In | 0.74 (0.42‐1.27) | .27 | 1.16 (0.61‐2.21) | .65 |
| Tobacco use | .73 | .80 | ||
| Never (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Former | 1.15 (0.81‐1.62) | 1.11 (0.73‐1.69) | ||
| Current | 1.04 (0.64‐1.67) | 1.19 (0.69‐2.04) | ||
| Body mass index (BMI), kg/m2 | 0.99 (0.96‐1.02) | .49 | 1.01 (0.98‐1.05) | .43 |
| Tertiles of systolic blood pressure at baseline | .05 | .25 | ||
| ≤ 124 mm Hg (reference) | 1.00 | 1.00 | ||
| 125‐140 mm Hg | 0.79 (0.55‐1.15) | 0.69 (0.44‐1.07) | ||
| ≥ 141 mm Hg | 0.60 (0.40‐0.91) | 0.79 (0.48‐1.28) | ||
| Baseline comorbid conditions | ||||
| Hyperlipidemia | 1.51 (0.67‐3.41) | .32 | 1.32 (0.44‐3.95) | .62 |
| Anxiety and/or depression | 1.39 (1.01‐1.90) | .043 | 1.49 (1.00‐2.23) | .05 |
| Dementia | 1.81 (0.91‐3.59) | .09 | 1.82 (0.80‐4.17) | .16 |
| Stroke and/or transient ischemic attack | 0.75 (0.40‐1.38) | .35 | 0.60 (0.30‐1.20) | .15 |
| Congestive heart failure | 0.90 (0.65‐1.25) | .53 | 0.86 (0.53‐1.41) | .55 |
| Chronic kidney disease | 1.22 (0.88‐1.68) | .23 | 1.13 (0.70‐1.83) | .62 |
| Peripheral vascular disease | 1.01 (0.74‐1.38) | .95 | 0.90 (0.61‐1.34) | .61 |
| Any diabetes complications (peripheral neuropathy and/or retinopathy) | 1.19 (0.85‐1.66) | .31 | 1.20 (0.80‐1.79) | .39 |
| Chronic obstructive pulmonary disease | 0.77 (0.55‐1.06) | .11 | 0.78 (0.49‐1.22) | .27 |
| Atrial fibrillation | 1.24 (0.83‐1.86) | .30 | 1.19 (0.71‐1.98) | .51 |
| Valvular heart disease | 1.03 (0.69‐1.54) | .87 | 1.15 (0.72‐1.83) | .56 |
| Solid organ malignancy | 1.49 (0.96‐2.33) | .08 | 1.44 (0.83‐2.52) | .20 |
| Ambulatory visits in baseline period | ||||
| Primary care | 1.02 (0.97‐1.06) | .47 | 0.99 (0.94‐1.05) | .77 |
| Specialty care | 1.07 (1.04‐1.10) | < .001 | 1.08 (1.04‐1.13) | < .001 |
BMI, body mass index; CI, confidence interval; HR, hazard ratio; kg/m2, kilograms per meters squared; mm Hg, millimeters Mercury; n, number. Bold value represents the significant at P < .05.
Table 4.
Unadjusted and adjusted hazard ratios and 95% CIs of independent predictors of achieving hypertension control (< 150/90 mm Hg) after an acute cardiac event among adults ≥ 80 years old with diabetes mellitus (n = 149)
| Variable | Unadjusted HR (95% CI) | P value | Adjusted HR (95% CI) | P value |
|---|---|---|---|---|
| Blood pressure medications by class | ||||
| Diuretics (including potassium‐sparing/aldosterone inhibitors) | 1.68 (0.98‐2.88) | .06 | 3.03 (1.40‐6.57) | .005 |
| ACE‐inhibitors or angiotensin II receptor antagonists | 1.21 (0.72‐2.05) | .47 | 0.62 (0.29‐1.31) | .21 |
| Beta‐blockers | 3.77 (1.38‐10.29) | .010 | 4.78 (1.54‐14.85) | .007 |
| Calcium channel blockers | 1.30 (0.88‐1.93) | .19 | 1.40 (0.85‐2.29) | .18 |
| Central acting/adrenergics & others | 1.56 (0.97‐2.51) | .07 | 1.41 (0.74‐2.69) | .30 |
| Female | 0.81 (0.55‐1.20) | .29 | 0.73 (0.41‐1.31) | .30 |
| Race/ethnicity | ||||
| White (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Nonwhite | 3.98 (1.23‐12.83) | .021 | 7.48 (1.02‐54.77) | .047 |
| Marital status | ||||
| Married/partnered (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Not married | 0.78 (0.53‐1.15) | .20 | 1.06 (0.59‐1.91) | .84 |
| CMS hierarchical condition categories (HCC) score | 1.03 (0.83‐1.28) | .78 | 0.84 (0.58‐1.21) | .34 |
| Medicaid Buy‐In | 1.38 (0.69‐2.74) | .36 | 0.85 (0.20‐3.56) | .83 |
| Tobacco use | .33 | .63 | ||
| Never (reference) | 1.00 | ‐ | 1.00 | ‐ |
| Former | 0.98 (0.66‐1.45) | 0.94 (0.54‐1.64) | ||
| Current | 0.41 (0.13‐1.33) | 0.51 (0.13‐2.00) | ||
| Body mass index (BMI), kg/m2 | 1.01 (0.97‐1.05) | .65 | 1.01 (0.95‐1.06) | .85 |
| Tertiles of systolic blood pressure at baseline | .31 | .26 | ||
| ≤ 124 mm Hg (reference) | 1.00 | ‐ | 1.00 | ‐ |
| 125‐140 mm Hg | 0.86 (0.54‐1.39) | 0.94 (0.53‐1.67) | ||
| ≥ 141 mm Hg | 0.70 (0.44‐1.11) | 0.61 (0.32‐1.15) | ||
| Baseline comorbid conditions | ||||
| Hyperlipidemia | 1.08 (0.66‐1.79) | .75 | 1.74 (0.87‐3.52) | .12 |
| Anxiety and/or depression | 0.87 (0.58‐1.29) | .49 | 1.39 (0.76‐2.56) | .29 |
| Dementia | 0.92 (0.54‐1.58) | .77 | 1.69 (0.78‐3.68) | .18 |
| Stroke/transient ischemic attack | 0.82 (0.46‐1.47) | .51 | 0.50 (0.24‐1.04) | .06 |
| Congestive heart failure | 0.93 (0.63‐1.37) | .70 | 0.95 (0.53‐1.70) | .87 |
| Chronic kidney disease | 1.09 (0.73‐1.63) | .68 | 1.22 (0.70‐2.12) | .49 |
| Peripheral vascular disease | 0.64 (0.43‐0.95) | .027 | 0.62 (0.34‐1.15) | .13 |
| Any diabetes complications (peripheral neuropathy and/or retinopathy) | 0.99 (1.66‐1.50) | .98 | 0.83 (0.48‐1.42) | .50 |
| Chronic obstructive pulmonary disease | 0.86 (0.57‐1.30) | .48 | 1.11 (0.63‐1.95) | .72 |
| Atrial fibrillation | 0.71 (0.46‐1.10) | .13 | 0.70 (0.40‐1.23) | .21 |
| Valvular heart disease | 0.94 (0.61‐1.45) | .79 | 1.01 (0.57‐1.79) | .98 |
| Solid organ malignancy | 0.85 (0.44‐1.64) | .64 | 0.71 (0.32‐1.58) | .40 |
| Ambulatory visits in baseline period | ||||
| Primary care | 1.06 (0.98‐1.14) | .12 | 1.01 (0.92‐1.11) | .76 |
| Specialty care | 1.09 (1.02‐1.16) | .007 | 1.07 (0.98‐1.16) | .13 |
BMI, body mass index; CI, confidence interval; HR, hazard ratio; kg/m2, kilograms per meters squared; mm Hg, millimeters Mercury; n, number. Bold value represents the significant at P < .05.
Interaction testing between age and individual antihypertensive classes demonstrated a significant interaction between ≥ 80‐year‐olds and diuretics, indicating that diuretics predicted achieving hypertension control among older adults (HR: 2.30; 1.23‐4.28, P = .002)—full data not shown. Additionally, there was a trend toward beta‐blockers predicting hypertension control among ≥ 80‐year‐olds (HR: 3.93; 1.41‐10.98, P = .06)—full data not shown. In a separate sensitivity analysis of antihypertensive combinations across therapeutic classes, adjusted Cox proportional hazards models did not demonstrate significant relationships between common antihypertensive combinations and hypertension control. Our findings were similar using 2 or 3 consecutive clinic visits at target blood pressure for the primary outcome of hypertension control.
5. DISCUSSION
Our study highlights that Medicare patients (≥ 68 years old) with diabetes and uncontrolled hypertension are more likely to achieve hypertension control after an initial cardiac event when prescribed beta‐blockers. Although the benefits of beta‐blockers after an acute cardiac event are established, this study demonstrates the importance of focused secondary prevention efforts in an older population.
The association of beta‐blockers and higher rates of hypertension control reflect guideline‐directed therapy for an acute coronary artery event. Although beta‐blocker prescriptions increased from baseline to discharge in our study, this alone will likely not explain the increased rates of hypertension control. According to US32, 33 and European34 guidelines, an acute cardiac event is a compelling indication to prescribe beta‐blockers, compared to other antihypertensives, to reduce risk of sudden cardiac death, arrhythmias, and heart failure.32 Beta‐blockers after an acute cardiovascular event also decrease rates of recurrent cardiovascular events.32
In our stratified analyses, beta‐blockers and diuretics significantly predicted hypertension control in adults ≥ 80 years old. This is an important finding given concerns about prescribing diuretics in older adults and the recent change in the US hypertension guidelines, supporting lower blood pressure goals in populations with high cardiovascular risk.33 Our comorbidity data demonstrated that this older population had a higher baseline diagnosis of congestive heart failure. Beta‐blockers are recommended at hospital discharge, specifically for patients with left ventricular systolic dysfunction (defined as an ejection fraction < 40%). Additionally, beta‐blockers have demonstrated a mortality benefit in patients with heart failure and left ventricular systolic dysfunction.35, 36 Finally, the beneficial antihypertensive property of diuretics in the older population also reflects a high prevalence of resistant hypertension in this older population.33
A large meta‐analysis demonstrated similar effects across most antihypertensives in reducing cardiovascular events and blood pressure reduction, except for beta‐blockers, which demonstrated a greater cardioprotective effect in the short term after a myocardial infarction.37, 38 Doses of other first‐ and second‐line antihypertensives (eg, ACE‐inhibitors/angiotensin II receptor antagonists; diuretics) may have been adjusted during the admission for an acute cardiovascular event. Our analysis does not support that beta‐blockers are better at hypertension control compared to other antihypertensives but reflects the importance of timely initiation of guideline‐directed care. However, antihypertensive medication is only part of an evidence‐based medication regimen for patients with diabetes mellitus and cardiovascular disease. Statins are also indicated after discharge for an acute cardiac event; importantly, statins and beta‐blockers have demonstrated a synergistic effect on overall short‐ and long‐term mortality in patients after CABG.39 Interestingly, more frequent specialty clinic visits were also associated with higher rates of hypertension control in our analysis. Primary care and specialty providers, including endocrinology and cardiology, managed our diabetes population. Therefore, our results underline the importance of multispecialty care and access to care within this complex population.
5.1. Limitations
Despite the important findings, there are limitations to this analysis. Although we were able to acquire prescription orders for antihypertensive medications, we were not able to assess patient medication adherence, which is a critical issue for secondary prevention of coronary artery disease.40 However, a recent hospitalization for an initial cardiovascular event may improve short‐term medication adherence41 in this older population; additional studies are needed. We were also unable to evaluate the type of beta‐blockers prescribed. Beta‐blockers are a very heterogeneous class; a future analysis evaluating cardioprotective and blood pressure lowering effects among the prescribed beta‐blockers will be very beneficial. We did not have 24‐hour ambulatory blood pressure data to confirm hypertension control; however, our sensitivity analysis demonstrated similar findings with using 2 or 3 consecutive visits with controlled blood pressures to define hypertension control. We were also unable to evaluate the net reduction in absolute blood pressure values; thus, we used a dichotomous outcome (controlled/uncontrolled blood pressure). The focus on a single provider group makes it difficult to know how generalizable the findings are to other provider groups and geographic regions. Although our study population was predominantly white, we hypothesize that these findings could be replicated in other races/ethnicities. Beta‐blockers are recommended for secondary prevention of coronary artery disease for white and nonwhite patients.12, 42 Clinical trials have also demonstrated similar benefits with carvedilol and metoprolol succinate among black and white patients with New York Heart Association class II‐IV heart failure.43 However, we did not assess serial ejection fractions and were unable to exclude participants with progressive left ventricular systolic dysfunction. Data were not available to compare our results to a control group without diabetes to evaluate possible mechanisms specific to a diabetes population. Finally, our sample size was limited when stratifying by age, as demonstrated by our wider confidence intervals; however, our findings were similar to prior studies in other populations.
6. CONCLUSIONS
Medicare patients with baseline diabetes and uncontrolled hypertension were more likely to achieve hypertension control within 1 year after discharge of an acute cardiac event if prescribed beta‐blockers at discharge and a history of more frequent specialty visits. Additionally, older patients (≥ 80 years old) were more likely to achieve control when diuretics were added to their antihypertensive regimen. These findings demonstrate the importance of multidisciplinary guideline‐directed care for this complex population.
CONFLICTS OF INTEREST
None declared.
AUTHOR CONTRIBUTIONS
H Johnson had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. A. Chaddha assisted in the interpretation of data, drafting of the manuscript, and critical manuscript revisions and provided final approval of the version to be published. M. Smith assisted with the design of the study, statistical analysis, interpretation of data, and critical manuscript revisions and provided final approval of the version to be published. M. Palta assisted in interpretation of data and critical revision of the manuscript for important intellectual content and provided final approval of the version to be published. H Johnson designed the study, performed the statistical analysis and interpretation of the data, drafted the manuscript, performed critical revisions of the manuscript for important intellectual content, and provided final approval of the version to be published.
Supporting information
ACKNOWLEDGMENTS
The authors gratefully acknowledge Aaron Potvien, PhD and Glenn Allen, MPH for data analysis, Katie Ronk, BS for data preparation, and Jamie LaMantia, BS for manuscript preparation. Each of these individuals worked for the University of Wisconsin‐Madison during this project and did not receive additional compensation above their normal salaries for their contributions.
Chaddha A, Smith MA, Palta M, Johnson HM. Hypertension control after an initial cardiac event among Medicare patients with diabetes mellitus: A multidisciplinary group practice observational study. J Clin Hypertens. 2018;20:891–901. 10.1111/jch.13282
Funding information
This project was supported by the Health Innovation Program, the University of Wisconsin School of Medicine and Public Health from The Wisconsin Partnership Program, and the Community‐Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR) through the National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. Grants R01 HS018368 and R21 HS017646 from the Agency for Healthcare Research and Quality also supported this project. Heather Johnson is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH), grant K23 HL112907. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funders did not play any role in the study design; in the collection, analysis, or interpretation of the data; in the writing of the manuscript; or in the decision to submit the article for publication.
REFERENCES
- 1. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA. 2002;287:2570‐2581. [DOI] [PubMed] [Google Scholar]
- 2. Miettinen H, Lehto S, Salomaa V, et al. Impact of diabetes on mortality after the first myocardial infarction. The FINMONICA Myocardial Infarction Register Study Group. Diabetes Care. 1998;21:69‐75. [DOI] [PubMed] [Google Scholar]
- 3. Herlitz J, Karlson BW, Lindqvist J, Sjolin M. Rate and mode of death during five years of follow‐up among patients with acute chest pain with and without a history of diabetes mellitus. Diabet Med. 1998;15:308‐314. [DOI] [PubMed] [Google Scholar]
- 4. Lee HS, Lee SS, Hwang IY, et al. Prevalence, awareness, treatment and control of hypertension in adults with diagnosed diabetes: the Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV). J Hum Hypertens. 2013;27:381‐387. [DOI] [PubMed] [Google Scholar]
- 5. Rao CR, Kamath VG, Shetty A, Kamath A. Treatment compliance among patients with hypertension and type 2 diabetes mellitus in a coastal population of Southern India. Int J Prev Med. 2014;5:992‐998. [PMC free article] [PubMed] [Google Scholar]
- 6. Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ. 2000;321:412‐419. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. UK Prospective Diabetes Study Group . Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. BMJ. 1998;317:720‐726. [PMC free article] [PubMed] [Google Scholar]
- 8. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335‐342. [DOI] [PubMed] [Google Scholar]
- 9. Hanefeld M, Fischer S, Julius U, et al. Risk factors for myocardial infarction and death in newly detected NIDDM: the Diabetes Intervention Study, 11‐year follow‐up. Diabetologia. 1996;39:1577‐1583. [DOI] [PubMed] [Google Scholar]
- 10. Sverre E, Peersen K, Otterstad JE, et al. Optimal blood pressure control after coronary events: the challenge remains. J Am Soc Hypertens. 2017;11:823‐830. [DOI] [PubMed] [Google Scholar]
- 11. Giorda CB, Avogaro A, Maggini M, et al. Recurrence of cardiovascular events in patients with type 2 diabetes: epidemiology and risk factors. Diabetes Care. 2008;31:2154‐2159. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. James PA, Oparil S, Carter BL, et al. 2014 evidence‐based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507‐520. [DOI] [PubMed] [Google Scholar]
- 13. Hebert PL, Geiss LS, Tierney EF, Engelgau MM, Yawn BP, McBean AM. Identifying persons with diabetes using Medicare claims data. Am J Med Qual. 1999;14:270‐277. [DOI] [PubMed] [Google Scholar]
- 14. Johnson HM, Thorpe CT, Bartels CM, et al. Undiagnosed hypertension among young adults with regular primary care use. J Hypertens. 2014;32:65‐74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Tu K, Campbell NR, Chen ZL, Cauch‐Dudek KJ, McAlister FA. Accuracy of administrative databases in identifying patients with hypertension. Open Med. 2007;1:e18‐e26. [PMC free article] [PubMed] [Google Scholar]
- 16. Kautter J, Pope GC, Trisolini M, Grund S. Medicare physician group practice demonstration design: quality and efficiency pay‐for‐performance. Health Care Financ Rev. 2007;29:15‐29. [PMC free article] [PubMed] [Google Scholar]
- 17. Pham HH, Schrag D, O'Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007;356:1130‐1139. [DOI] [PubMed] [Google Scholar]
- 18. Thorpe CT, Flood GE, Kraft SA, Everett CM, Smith MA. Effect of patient selection method on provider group performance estimates. Med Care. 2011;49:780‐785. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Rosendorff C, Writing C. Treatment of hypertension in patients with coronary artery disease. A case‐based summary of the 2015 AHA/ACC/ASH scientific statement. Am J Med. 2016;129:372‐378. [DOI] [PubMed] [Google Scholar]
- 20. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich). 2014;16:14‐26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Johnson HM, Thorpe CT, Bartels CM, et al. Antihypertensive medication initiation among young adults with regular primary care use. J Gen Intern Med. 2014;29:723‐731. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Taylor DH Jr, Fillenbaum GG, Ezell ME. The accuracy of Medicare claims data in identifying Alzheimer's disease. J Clin Epidemiol. 2002;55:929‐937. [DOI] [PubMed] [Google Scholar]
- 23. Taylor DH Jr, Ostbye T, Langa KM, Weir D, Plassman BL. The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited. J Alzheimers Dis. 2009;17:807‐815. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Foley RN, Murray AM, Li S, et al. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999. J Am Soc Nephrol. 2005;16:489‐495. [DOI] [PubMed] [Google Scholar]
- 25. Newton KM, Wagner EH, Ramsey SD, et al. The use of automated data to identify complications and comorbidities of diabetes: a validation study. J Clin Epidemiol. 1999;52:199‐207. [DOI] [PubMed] [Google Scholar]
- 26. Pope GC, Kautter J, Ellis RP, et al. Risk adjustment of Medicare capitation payments using the CMS‐HCC model. Health Care Financ Rev. 2004;25:119‐141. [PMC free article] [PubMed] [Google Scholar]
- 27. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245‐1251. [DOI] [PubMed] [Google Scholar]
- 28. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373‐383. [DOI] [PubMed] [Google Scholar]
- 29. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD‐9‐CM administrative databases. J Clin Epidemiol. 1992;45:613‐619. [DOI] [PubMed] [Google Scholar]
- 30. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8‐27. [DOI] [PubMed] [Google Scholar]
- 31. Li P, Kim MM, Doshi JA. Comparison of the performance of the CMS Hierarchical Condition Category (CMS‐HCC) risk adjuster with the Charlson and Elixhauser comorbidity measures in predicting mortality. BMC Health Serv Res. 2010;10:245. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non‐ST‐elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2354‐2394. [DOI] [PubMed] [Google Scholar]
- 33. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. JACC. 2017. doi: 10.1016/j.jacc.2017.11.005. [Epub ahead of print]. [DOI] [Google Scholar]
- 34. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST‐segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2017;39:119‐177. [DOI] [PubMed] [Google Scholar]
- 35. Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left‐ventricular dysfunction: the CAPRICORN randomised trial. Lancet. 2001;357:1385‐1390. [DOI] [PubMed] [Google Scholar]
- 36. McMurray J, Kober L, Robertson M, et al. Antiarrhythmic effect of carvedilol after acute myocardial infarction: results of the Carvedilol Post‐Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN) trial. J Am Coll Cardiol. 2005;45:525‐530. [DOI] [PubMed] [Google Scholar]
- 37. Andersson C, Shilane D, Go AS, et al. Beta‐blocker therapy and cardiac events among patients with newly diagnosed coronary heart disease. J Am Coll Cardiol. 2014;64:247‐252. [DOI] [PubMed] [Google Scholar]
- 38. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta‐analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39. Philip F, Blackstone E, Kapadia SR. Impact of statins and beta‐blocker therapy on mortality after coronary artery bypass graft surgery. Cardiovasc Diagn Ther. 2015;5:8‐16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Korhonen MJ, Robinson JG, Annis IE, et al. Adherence tradeoff to multiple preventive therapies and all‐cause mortality after acute myocardial infarction. J Am Coll Cardiol. 2017;70:1543‐1554. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Akincigil A, Bowblis JR, Levin C, Jan S, Patel M, Crystal S. Long‐term adherence to evidence based secondary prevention therapies after acute myocardial infarction. J Gen Intern Med. 2008;23:115‐121. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289:2560‐2572. [DOI] [PubMed] [Google Scholar]
- 43. Egan BM, Basile J, Chilton RJ, Cohen JD. Cardioprotection: the role of beta‐blocker therapy. J Clin Hypertens (Greenwich). 2005;7:409‐416. [DOI] [PMC free article] [PubMed] [Google Scholar]
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