An Older Woman with Peripheral Arterial Disease

To the Editor:
I have a question in regard to the article “An Older Woman with Peripheral Arterial Disease” by Dr. Wilbert Aronow from the May issue (Geriatrics & Aging 2006;9:378). The author writes “…Beta-blockers should be administered because she has a prior MI and an abnormal LVEF to reduce cardiovascular morbidity and mortality.” That’s true, but what happens with beta-blockers and PAD in this patient--are they not contraindicated?
Marilú Budinich Villouta, MD, Geriatrics Resident, Mayor University, Capredena La Florida Rehabilitation Centre, Santiago, Chile.

Dr. Aronow replies:
A meta-analysis of 11 randomized, controlled trials demonstrated that beta blockers do not adversely affect walking capacity or the symptoms of intermittent claudication in patients with mild to moderate peripheral arterial disease (PAD).¹

Of 490 men and women, mean age 80 years, with symptomatic PAD and prior myocardial infarction (MI) without contraindications to beta-blockers, 257 (52%) were treated with beta-blockers.² Adverse effects causing cessation of beta-blockers occurred in 31 of these 257 patients (12%). At 32-month follow-up, use of a beta-blocker was associated with a 53% significant independent reduction in the incidence of new coronary events in older patients with PAD and prior MI.²

In a vascular surgery clinic, 301 of 364 patients (83%), mean age 71 years, with PAD and coronary artery disease were being treated with beta-blockers.³
Finally, the American College of Cardiology/American Heart Association 2005 practice guidelines for the management of patients with PAD recommend beta-blockers as antihypertensive therapy in patients with PAD to reduce MI, stroke, congestive heart failure, and cardiovascular death with a Class I recommendation.⁴
Wilbert S. Aronow, MD, Clinical Professor of Medicine, New York Medical College, Valhalla, NY.

References

1. Radack K, Deck C. Beta-aderenergic blocker therapy does not worsen intermittent claudication in subjects with peripheral arterial disease: meta-analysis of randomized controlled trials. Arch Intern Med. 1991;151:1769-76.
2. Aronow WS, Ahn C. Effect of beta blockers on incidence of new coronary events in older persons with prior myocardial infarction and symptomatic peripheral arterial disease. Am J Cardiol 2001;87:1284-6.
3. Sukhija R, Yalamanchili K, Aronow WS, et al. Clinical characteristics, risk factors, and medical treatment of 561 patients with peripheral arterial disease followed in an academic vascular surgery clinic. Cardiol Rev 2005;13:107-9.
4. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary. Circulation 2006;113:1474-547.