Heart studies surprise doctors Hormone therapy doesn't show benefit, but beta blockers do

August 19, 1998|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

New heart studies published yesterday are confounding the long-held expectations of many physicians.

In the first study of its kind, hormone replacement therapy -- widely expected to protect against heart disease -- did not show any cardiovascular benefit over four years.

In two other studies, including one from the University of Maryland Medical Center, an old class of heart drugs -- beta blockers, which physicians have been reluctant to prescribe to the sick and elderly -- proved it could save these patients' lives.

The findings confront the most basic of health questions: how best to treat the nearly 14 million people who have heart disease, the nation's No. 1 killer?

"I was shocked," said Dr. Roger S. Blumenthal, a cardiologist and director of the Ciccarone Center for Prevention of Heart Disease at Johns Hopkins Hospital. He and other researchers nationwide had expected to see as much as a 50 percent drop in cardiac events among women taking the hormone therapy. Previous observational studies had shown similar improvements.

But the gold standard in science is a clinical trial, in which patients are randomly given a drug or a dummy pill and then studied. In the first clinical trial to address the question of hormone replacement therapy and heart disease, women receiving the therapy gained no cardiovascular benefit.

The study, published in today's Journal of the American Medical Association, focused on older women with a history of heart disease -- not the majority of younger women who take hormone replacement therapy for menopausal symptoms or osteoporosis.

"When investigators and coordinators first found out about it, there were a lot of blank stares, and it was really hard to believe that this was the case," Blumenthal said, adding that physicians "now can cross off" estrogen as a high-priority therapy to investigate further.

Higher priority

With the two other studies, beta blockers now take a higher spot on that priority list.

Discovered in the 1960s, this class of drugs slows the heart rate, decreases irregular heartbeats and makes the heart work less hard, which can decrease angina. Metoprolol, propranolol and other beta blockers have been proven to substantially increase the chances of survival of heart patients, yet many -- especially the elderly and those with chronic conditions -- are not getting the drugs.

For years, doctors have worried that, among these patients, side effects -- such as fatigue, depression, sleep disturbances and sexual dysfunction -- could mean beta blockers would cause more harm than good. For those with diabetes, for instance, beta blockers might mask the effects of hypoglycemia, low blood sugar.

But little study of beta blockers had been done on the elderly and those with chronic conditions. The researchers at the University of Maryland Medical Center examined the medical records of 201,752 Medicare patients who had heart attacks, and they found the drugs helped everyone.

"The bottom line is we could not identify a group of patients who did not benefit from beta blockers," said Dr. Stephen S. Gottlieb, director of the cardiac care unit at Maryland.

Published in this week's New England Journal of Medicine, the study found that overall, only 34 percent of the group were on the drugs. Over two years, those taking the drug had a 42 percent greater chance of survival, no matter what their age, medical condition or heart function.

That translates into almost 20,000 people whose lives would have been saved by medication.

"These findings should prompt all physicians to routinely prescribe beta blockers for their patients following a heart attack," Gottlieb said.

A wake-up call

Some physicians are warning that sweeping recommendations should not be made about the use of beta blockers because, in their study, researchers had to group together all those with certain conditions, such as diabetes, irrespective of the severity of their conditions. But many cardiologists describe the study as a wake-up call to physicians.

"We're at the point now where you've got to have a pretty strong reason not to use beta blockers in patients with heart attacks," said Dr. Sidney Gottlieb, a cardiologist in the Mid-Atlantic Cardiovascular Associates, the largest group in the region. (He is not related to Stephen Gottlieb.)

A second study on beta blockers, published yesterday by researchers at Yale School of Medicine, found that, of the more than 45,000 patients 65 and older who were considered ideal candidates to receive beta blockers, only half were prescribed the drug before discharge from the hospital. One year later, these patients had a 14 percent lower risk of death.

In both arenas -- beta blockers and hormone replacement therapy -- experts said treatment decisions will often come down to a frank talk between doctor and patient.

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