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CLINICAL STUDIES

Health outcomes associated with beta-blocker and diltiazem treatment of unstable angina

Nicholas L. Smith, PhD, MPH^* , Gayle E. Reiber, PhD, MPH ^¶, Bruce M. Psaty, MD, PhD^* , Susan R. Heckbert, MD, PhD, David S. Siscovick, MD, MPH^* , James L. Ritchie, MD, FACC^{* ||}, Nathan R. Every, MD, MPH^{* || ¶} and Thomas D. Koepsell, MD, MPH

^* Department of Medicine, University of Washington, Seattle, Washington, USA
Department of Epidemiology, University of Washington, Seattle, Washington, USA
Department of Health Services, University of Washington, Seattle, Washington, USA
^|| Department of Cardiology Service, Veterans Affairs Puget Sound Health Care System, Seattle Division, Seattle, Washington, USA
^¶ Health Services Research and Development Service, Veterans Affairs Puget Sound Health Care System, Seattle Division, Seattle, Washington, USA

Manuscript received March 17, 1998; revised manuscript received June 23, 1998, accepted July 9, 1998.

Address for correspondence: Dr. Nicholas L. Smith, Cardiovascular Health Research Unit, 1730 Minor Avenue, Suite 1360, Seattle, Washington 98101
nlsmith{at}u.washington.edu

Objective. We compared long-term health outcomes associated with beta-adrenergic blocking agents and diltiazem treatment for unstable angina.

Background. No long-term data have been published comparing these two antianginal treatments in this setting.

Methods. Eligible veterans were discharged from the Veterans Affairs Puget Sound Health Care System (VAPSHCS), Seattle Division, between October 1989 and September 1995 with an unstable angina diagnosis and were prescribed monotherapy beta-blocker or diltiazem treatment at discharge. Medication data were collected from medical records and computerized VAPSHCS outpatient pharmacy files. Follow-up death and coronary artery disease rehospitalization data were collected through 1996. Proportional hazards regression compared survival among diltiazem and beta-blocker users, controlling for patient characteristics with propensity scores.

Results. Two hundred forty-seven veterans (24% on beta-blockers, 76% on diltiazem) were included in this study. There were 54 (22%) deaths during an average follow-up of 51 months. After propensity score adjustment, there was no difference in risk of death comparing diltiazem to beta-blocker treatment (hazards ratios [HR] 1.1; 95% confidence interval [CI] 0.49 to 2.4). Among Washington residents (n = 207), there were 146 (71%) coronary artery disease rehospitalizations or deaths during follow-up. After adjustment, there was a nonsignificant increase in risk of rehospitalization or death associated with diltiazem use (HR 1.4; 95% CI 0.80 to 2.4). For both analyses, similar risks were found among veterans without relative contraindications to beta-blockers.

Conclusions. We found no survival benefit of diltiazem over beta-blocker treatment for unstable angina in this cohort of veterans.

Abbreviations and Acronyms   BIRLS = Beneficiary Identification and Record Locator Subsystem   CABG = coronary artery bypass grafting   CHARS = Comprehensive Hospital Abstract Reporting System   COPD = chronic obstructive pulmonary disease   ECG = electrocardiogram   ICD-9 = International Classification of Disease, 9th Edition   MI = myocardial infarction   PTF = patient treatment file   VAPSHCS = Veterans Affairs Puget Sound Health Care System

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