Use of beta-blocking agents in secondary prevention after myocardial infarction: a case for evidence-based medicine?: GISSI experience, 1984-1993

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Abstract
Many clinical trials conducted in the 1970s and early 1980s have shown that the long-term use of beta-blockers after an acute myocardial infarction significantly reduces mortality and reinfarction rates. This study assessed the impact of these findings in clinical practice. We retrospectively analysed the beta-blocker prescriptions for 36 817 patients with acute myocardial infarction included in three large randomized clinical trials (Gruppo Italiano di Studio sulla Sopravvivenza nell'Infarto Miocardico—GISSI, 1, 2 and 3), conducted by a highly representative sample (about 75%) of Italian coronary care units in 1984–85, 1988–89 and 1991–93. The prescription of beta-blockers at discharge increased gradually from 8·5% in 1984–85 to 25·0% in 1988–89 and to 31·4% in 1991–93. A similar trend was apparent for beta-blocker prescriptions 6 months after acute myocardial infarction. The strongest predictors of beta-blocker prescription are the presence of post-infarctual angina and a history of arterial hypertension. Besides the classical contraindications, advanced age, transitory cardiac failure or arrhythmias in the acute phase of acute myocardial infarction are important predictors of nonprescription. The use of beta-blockers after acute myocardial infarction in Italy has increased more than three-fold in the last decade, but they are still prescribed to too few patients, especially those at higher risk, for whom the expected benefit is greater.

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