Beta blockers after heart attacks don't work | A failed quality metric

Vinay Prasad, MD MPH; Physician & Professor
Hematologist/ Oncologist
Professor of Epidemiology, Biostatistics and Medicine
Author of 450+ Peer Reviewed papers, 2 Books, 2 Podcasts, 100+ op-eds.
If you want to contact me, do it here: www.vinayakkprasad.com/contact
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Podcast Website: www.plenarysessionpodcast.com
Academic Publications: www.vinayakkprasad.com/papers
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Twitter @vprasadmdmph

[@GlobalShutterNY]

As a practicing physician I find your presentations wonderful - debunking old wives tales and gut-feelings and intuitions with actual data and science!

[@EB-bl6cc]

science should be about questioning EVERYTHING and taking nothing for granted but so few do that

[@olympiashorts]

Speaking of which. I just recently saw that the prohibition against drinking alcohol while using metronidazole was based on a case report in the 1960’s and backed up by more case reports. A more recent study (case control I believe) revealed no disulfiram effect. So the next time I get giardia I am not laying off the bourbon.

[@markwebb7179]

I feel like Prasad is filling an important niche in the decades-long transition from what we were doing into a world of evidence-based medicine. Basically all he has to do is keep repeating, "You can't rely on old case reports anymore!" We need well-designed RCTs to design good medical practice, but we're stuck with what was defined fifty years ago as "good medical practice". We think medicine is evidence-based in theory, but there's a lot of theory out there that never lived up to basic standards of evidence before it was adopted and became sacrosanct. The project of weeding that out and replacing it with good medicine will take a long time. And as Prasad points out, in the meantime we'll still face the problem of evidence having a shelf life.

[@nykka3]

@@olympiashortsgood to know. I will keep that in mind when prescribing Flagyl for the next patient diagnosed with bacterial vaginosis.

[@toddrf]

Can you imagine being a doctor treating Vinay for a condition and trying to prescribe him a medication?

[@dedetudor.]

😅that would be interesting!

[@GregPlaugherDCChiropractor]

I can’t imagine it;)

[@Andy_T79]

Doctors self-prescribe, even if not ethical.

[@sl4983]

Lol! So hilarious!

[@jocelyncarvlin5045]

😂I’m dying

[@MyPerennial]

Was so excited when this paper dropped. Blocking someones exercise tolerance and sapping their energy at the moment they need it to heal from a myocardial insult is a fools errand.

[@ybrueckner5589]

So great to think we can liberate esp male patients but also depressed women post MI

[@creeky3751]

I sure do enjoy your videos and I'm not even in the medical field. Keep them coming. Thanks

[@stephencheung6614]

Goodhart’s law: “every measure which becomes a target becomes a bad measure”

[@jasonlopez4803]

Interesting study! As a medical student on my medicine rotation we had a handful of patients with HFrEF that just couldn't tolerate their BBs. It would immediately cause them to be fluid overloaded and decompensate. Not the same population but more reason to be judicious with BB prescribing.

[@oliverallen5324]

Hear hear.

[@michaelburatovich3199]

Did those patients tolerate verapamil or diltiazem?

[@chunkchips4554]

Combined with a diuretic?

[@rafaelalbertotorres8070]

Also. consideration on other comorbidities and whether to select a beta-selective blocker or not is very important.

[@Ninjamama22]

Thanks for being an outspoken advocate for common sense medicine in a mad, mad world. Also, love the haircut. 👍🏻

[@ideasmatter4737]

How can we get you as our Surgeon General, sir?

[@Closertotruth2]

I know you are not a Trump fan VP. However, when he wins and asks you to head the FDA I hope you accept for the good of the country.

[@c.m.8776]

Could you please do a video about the quality metrics and why they’re useless? That would be extremely helpful. I am a 3rd year medical student and this topic is almost completely ignored in medical education. Ofc Various schools teach more or less about it, but overall it is spoken of positively but vaguely.

[@laveraparato258]

Thank you for not over prescribing medication!

[@embededfabrication4482]

Look man, there are many people in pharma redundant jobs depending on selling drugs that don't do anything.

[@jercasgav]

Like statins for the majority of people...esp all women and men that have not yet had heart attacks.

[@gstlynx]

To the point about "everyone should be randomized, all the time". Well, you can't do that b/c people at the NIH are steering grants to high probability high profit research that will ultimately line their pockets.

[@katdeekelly3228]

Can you plssssss do a video on statins and their studies! ❤

[@robincray116]

Goodharts Law from Economics: "If a measure/metric becomes the goal/target, it ceases to be a good measure." It describes the inherit issue that once a complex problem is described by a set of simplified metrics and the metric themselves become the goal, the metric no longer represents the problem because people start gaming the system to improve their metrics not solve the problem the metric is trying to represent. I remember an anecdote from university. Air Malaysia once wanted to improve the time it took to get air luggage into the pick up area. Their metric was the time it took to get first luggage into the area. What ended up happening was that when the plane landed they unloaded a single piece of luggage and rushed it into the pick up area.

[@0num4]

Thanks for shedding light on this, Doc! Remember, the scientific *method* is infallible--scientific *practitioners* however, are just as human as the rest of us.

[@agfairfield8575]

Care to tackle statins next???

[@casapilanola]

thank you so much, Dr. Prasad, as ever, for your commitment to truly honest and science-based approaches to your chosen topics. Wishing you long health and prosperity!

[@theodorewojcik2027]

This is a great video vinay! very insightful. I will present this in journal club! Thanks!

[@olibertosoto5470]

You mean to tell me that we've been giving people treatments that they may not need and be better off not having - but this was during a barbaric era and not today!!! Well, glad this didn't happen recently - like around 3 years ago!

[@brebeufgarcia1090]

I had a MI in 2010, then a stroke in 2021 due to A-Fib tachycardia event and condition. The heart docs in Kaiser Permanente id SF, CA USA prescribed 20mg of beta blocker Metoprolol. It sounds like from the current study your were presenting, my beta blocker and its dosage are medically useless and possibly inadvisable to continue on. I'll have to send a link to your video and the study you have explicated well. Thank you.

[@cartermayfield]

I am curious about your take on the latest Paxlovid study, which looks a little like trash.

[@gparsr]

Oh don’t worry. That epic presentation is surely in the works!!

[@dedetudor.]

It was.

[@8aNda1d]

He trashed that even before this last report

[@dedetudor.]

@@8aNda1d I love Dr Prasad. I haven't always agreed with him, esp. in the beginning, but his accuracy over all is brilliant.

[@dedetudor.]

@@8aNda1d he read them like yesterday's news.

[@cmorganwpi]

Imagine the amount of dollars (energy, co2 etc) savings if efficacy was a factor in medicine.

[@eldergeektromeo9868]

Wow! Thanks (again) Doc!

[@sebhaterqou9733]

The reason some people point to wider confidence interval, or ask for more data in questions such as beta-blockers post MI maybe because of expectations about the effect based on prior knowledge (e.g. prior trial data). I believe there is a value to using Bayesian approach to interpreting p-values and confidence intervals. The same expectation does not usually exist for a new drug.

[@markcohen4117]

Just a quibble: to describe care from the late 70’s- 80’s as barbaric is a bridge to far. Twas the dawn of randomized trials in cardiac and the development of the idea of intervention- the types of which may well have obviated the data driven care of that era. To re examine our prior data driven care in light of new drugs, devices and paradigm to move forward does not make the prior well informed data driven care of that era “ barbaric”. As a physician who came of age caring for pts then and now, thru the development of cardiac interventions- that many the described as barbaric- subsequently proven to be of benefit. We stand on the Shoulders of Giants. Love your talks . Stats are poorly taught in medicine- but would offer a word of caution with respect to prior well intentioned and data driven care. We do things differently because we continue to randomize and learn.

[@justinburch]

I was put on Beta blockers and I was nearly passing out regularly and had to give up all forms of exertion. My blood pressure did not go down uniformly. The upper number went way up and the lower number went way way down. After three months of being a zombie I just quit taking them and I have refused to take the stuff anymore.

[@reginamemoriesforever-vc8ql]

Unbelievable what doctors are doing to people… they lost their minds.

[@LofotenDoc]

Thank you for the review of or study. Multiple other trials are testing the question of midrange LVEF 40%. However if you look at the data there is not the therapeutic equipoise - IMO - for these patients and I also believe these studies will show and interaction, but they will not have power for a primary outcome in those with EF equal to or above 50%. Best Dr Yndigegn, first author.

[@daviddobies2993]

You make great points. Thank you.

[@dansolomon4520]

Brilliant, love your enthusiasm and highlighting key points. Will you do one on mechanism for protective cardiovascular effects of these drugs? Thanks

[@ilsemalan3542]

I think you are so good I listen to everything you say

[@carolharrison5780]

Imagine how much you could learn if he was your patient. We’d all look up research for possible diagnosis, tx & #1 best bedside manner!!!

[@DrTomMD]

This was an excellent presentation vis a vis content and delivery. Never been a big fan of Bb’s. Their side effects are often QoL sapping (eg activity tolerance) and, depending on which, not particularly favorable for insulin resistance or dyslipidemia. Not sure about ongoing registry randomization without consent. Have to think through that. Maybe another video dedicated to that question? Nevertheless, will be forwarding this video to colleagues.

[@Photoshop729]

For those keeping score: Medications that work: penicillin, Medications that don’t: All the other ones, no matter how expensive or pseudoscientific they sound

[@sl4983]

Zolpidem works

[@robinhood4640]

What about Lemsip?

[@westfield90]

But most people after Mi do not have preserved ejection fraction. So do beta blockers help these people?

[@kikbek]

IM guy here, really appreciate your videos brother

[@trippyhippie8630]

I’ve been following you for a long time Dr. You get all the stats

[@cecumseeker]

Quality metrics are also tools for big pharma and device manufacturers to sell more

[@atfinthehouse8631]

Really more and more seems we uncover more data that goes against decades old guidelines. Will the organizations of physicians that assess how well physicians are doing change these quality measures?

[@justinburch]

In Canada any physician who speaks out against the Big Pharma standards of care can lose their license. We no longer have informed consent or a private individualized doctor patient relationships in Canada.

[@rafaelalbertotorres8070]

BB are definitely overused, and many times improperly used in patients with other comorbidities, used for non-approved conditions for a particular BB, or not taking into account beta-selectivity.

[@walterbortz355]

My God VP, your points are so relevant and thoughtful. I would love to hear your thoughts about the cost/benefit balance of anticoagulation in atrial fibrillation, an enormous marketplace item in medicine and a guideline paradise for those interested in steamrolling any nuanced recommendations.

[@debrafloeter2816]

Would love a discussion on that topic too. I'm in "that" age group where over half my friends and neighbors are on every kind of anticoagulant (55+ community). And some are running to a "Coumadin Clinic" for blood every 2 weeks. 🤔😮‍💨

[@jercasgav]

I am 38yrs old, and my 58yr old dad was just hospitalized for a. fib this past week. Prior to this he was overall a healthy man esp for his age with no previous major medical issues, in shape, healthy weight. Of course now he is on lifelong coagulants, and I would love to know the answer to this as well.

[@justinburch]

I developed anemia and microbleeds into my joints while on plavix so I was in terrible pain. I had a bone marrow test and was told I had Chronic myelomonocytic leukemia. I was told after a minor stroke that I had to take plavix for the rest of my life. I stopped taking plavix and it took about four months but all my arthritic symptoms vanished and my anemia and CMML corrected itself. I am told that having CMML correct itself can't happen.

[@michaelryeburn425]

There is a difference between "shows that there is not a difference" and "does not show that there is a difference". The later is true of this study

[@JP-su1eg]

Yes! Absolutely, this is the distinction I took.

[@michaelryeburn425]

@@JP-su1eg Probably the conclusion is correct that B-blocker don't help for MI with preserved ejection fraction. But also quite possible that B-blockers reduce death or repeat MI, but just not strong enough effect o meet significance without a larger sample size. Need more studies with larger number of patients from different populations before we extrapolate this to MI patients as a whole. Just wondering how this passed ethics review. I can't imagine doing a study where you withhold a treatment that has been generally accepted as lifesaving.

[@jamesleem.d.7442]

Bravo

[@fredbloggs8816]

. Very interesting this, in my case, Post STEmi with PEF, , a much smaller dose than 100mg dropped my heart rate into the low 40s reducing cardiac output - it took me to push GP and hospital to change from UK NICE recommendations. So what was the supposed benefit?

[@justinburch]

Big Pharma made money while you were on the drugs. That's the benefit.

[@cheapskatesnob]

That's unfortunate, what are people's options post heart attack?

[@victorinewarner5670]

Diet mostly. All natural from scratch, no processed, life long grass fed meats. And start Walking

[@sl4983]

Aerobic

[@sl4983]

Aerobic

[@sl4983]

See Dean Cornish

[@carl13579]

See the dietary work of cardiologist Dr. Caldwell Esselstyn. I'm an example of someone who has reversed their angina post heart-attack.

[@flowersinherhair]

I am a year post-MI with one stent in (on the right.) I am on beta blockers,metroprolol 25mg BID. My EF is over 60 percent. Im on 2 other drugs for hypertension. What should i say to my cardiologist?

[@justinburch]

If you're in Canada your cardiologist can't tell you the truth but instead must impose Big Pharma standard of care on you. Talk back. You get a note in your file about being a difficult patient who refuses to follow orders. This protects your doctor from losing his license.

[@janaka861]

Maybe I am missing something: Where is the reference to the paper and how do I get a copy?

[@marlenegold280]

Is Dr. Prasad saying that transplantation with Multiple Myeloma was found to not work?

[@patrickmurray2340]

Be interesting with all the stroke metrics because they are almost all time based.. like all the nursing care is also super monitored by administrators.

[@auricauric8150]

Plz link article

[@Teresamaze1]

Im about to have stents . 80 percent blockage. Im on beta blocker so it doesnt work ? I have 2 80 percent and a 60 and a 30

[@bjs301]

Does this have relevance for patients post- bypass? I suffered what they called a "widow maker" 2 years ago, and underwent triple bypass. I was on Eliquis for several months post-surgery, and have been on metoprolol and baby aspirin since then. I am a layman Does this study suggest these drugs aren't worth continuing? I will say my blood pressure has done fairly well on the drugs.

[@twistersister-wd9bl]

Listen to your doctors! Vinay is speaking in general terms, not about specific cases

[@James-dc3yt]

@@twistersister-wd9bl The doctors are doing with Big Pharma tells them

[@bjs301]

@@twistersister-wd9bl I will. I was just curious, but after what I've been through, I definitely won't stop taking any med other than as directed by my cardiologist. Thanks!

[@JanRoman119]

Vinay, it would be great if you listed and explained the terms used so people can better understand your argument. For example I never heard of « perfusing « people after MI. 10:18

[@carl13579]

That's the clot-buster drugs. It can also be surgical intervention. Perfusing means restoring healthy blood flow to tissue damaged by impairment of that blood flow.

[@davidmsperry]

"The landscape has changed..." Do most of us now (post three jabs) have elevated levels of igg4? Do most of us have immortal non-classical monocytes and abnormal proteins?

[@sl4983]

Your new video on the breast cancer med is being buffered/ censored

[@danielgsfb]

'"The absence of evidence is not evidence of absence. That`s another thing that`s a stupid thing to say". Dude, I was drinking my juice and spilled everything. hahahaha, got to love these aggressive comments

[@RNG-999]

I have had two heart attacks since June 2022 as a 26 year old male. I developed myocarditis after getting my vaccinations (Moderna twice) as I have worked in healthcare and on the frontlines since Day 0 Covid. I was in THE facility here in Washington state that became one of the only Covid-19 rehabilitation centers in America for a period of 12 months or so. My two mild myocardial infarctions have now progressed into silent myocardial ischemia and my doctor was JUST ABOUT TO PRESCRIBE ME Beta-Blockers in order to repair heart damage. Now you are telling me that they don't work for this? Well... What are my options now?

[@laveraparato258]

I hope you can find a long covid/vaccine injury doctor.

[@juneelle370]

All I can say is that if you have a medical condition, research as much as you can, every day until you find something promising to try. Learn to read studies, don’t be afraid to ask questions and run from doctors who run from questions (as in-wanting to see the studies validating the treatment/surgery offered or hypotheses of the treatment) because their arrogance will cause you more harm than good. And besides research, finding such a doctor is another necessary quest. I know all this from experience and I was fortunate to see a doctor who didn’t know the answers but confirmed my situation was dire/serious and told me that “if I were you, I’d sit my behind in that wheelchair in front of a computer every day until I found a cure” and it’s exactly what I did. I’d been researching before but doctors were so arrogant that they didn’t want to even look at it and his words encouraged me to go on. I’m forever grateful to him. No one’s going to care more about your health, your life than you. Also, 🙏☀️❤️

[@chunkchips4554]

Calcium channel blockers, nitroglycerin, digoxin, ace and arbs. I'd look into it

[@chunkchips4554]

Arbs and aces...

[@sl4983]

Did you report the adverse effect to VAERS or another reporting system? Don't trust your doctor to do it.

[@melissaholton2772]

Totally believe the dyspnea worse on a beta blocker. That was my experience taking it as a healthy 20 yo who had som HTN on an OCP. I’ve got another amazing quality metric - exclusive breastfeeding - not among when who desire exclusive breastfeeding, but among all comers. Anything we can do to decrease the administrators!!!!!!!!!!

[@jeffreyschroeder9350]

This is old news. BBs have not been recommended in HFpEF for awhile. Nice to confirm but….

[@timswack7230]

Hey Vijay, When are you going to cover the evidence base for gender affirming care?

[@ArtU4All]

Have you heard? Zero studies. Zero evidence. Zero long-term follow-up. You are at the mercy of the ideology and misinformed consent, and in pediatric cases - absence of consent

[@burtnation1357]

😮

[@Skicloud1888]

What’s on your finger?

[@sl4983]

Yes what was with that?

[@michaelburatovich3199]

I wonder if those post-MI patients who lower ejection fractions would benefit from beta-blockers? Someone really needs to study the sub50% EF patients in post MI.

[@raymondmeyers8983]

Beta Blockers are standard guideline directed medical therapy for all patients with reduced ejection fraction post-MI or not. That’s why they weren’t included.

[@justinburch]

@@raymondmeyers8983 Also "standard of care" for post stroke patients. I know because I was put on them after a mild stroke, hardly more than a TIA and I quit because of horrific side effects, especially zero exercise tolerance and passing out if I even took a gentle walk.

[@raymondmeyers8983]

@@justinburch If you can't tolerate them, you can't tolerate them and then they're not prescribed. Otherwise you give them.

[@justinburch]

@@raymondmeyers8983 That's weird because every time I have contact with any doctor the first thing they ask is why I'm not on Beta blockers, every single time. Standard of care requires I have to constantly justify why I am not taking them. And more than one doctor acted like I was making it all up and should take them anyway.

[@raymondmeyers8983]

@@justinburch why is is it weird. They ask because they’re normally prescribed for someone with your history. It may be annoying to constantly answer that question but they’re just being good doctors when they inquire why you’re deviating from the standard of care.

[@garyanderson7050]

What is going on with your finger?

[@sl4983]

Following

[@sl4983]

I wonder if it's the bandaid signal

[@mballer]

13:13 Show me the beer studies. Is beer health provoking?

[@jpg7186]

Well they did wimp out on the inclusion population (pEF only) but now next year's trainee's can participate in studying the rEF population...5 will get you 10 that the rEF population also do not receive benefit

[@beenjammin8581]

I’ve been arguing this for years

[@patrickhaarhues2870]

I bet we see same about jardiance in chf diabetics. I think you might have hope after all presad. Big pharma pays for the studies and media and physicians gobble it up.

[@LilJbm1]

But we'll have to update the MONABASH mnemonic! MONAASH just doesn't hit the same 💩

[@gnormhurst]

"Doc, what's with the coin?" "Oh, it's how I decide how to treat you." I mean, from a big-data policy standpoint randomizing all patients makes sense, but it feels a little weird at the clinical level. Fundamentally, doctors are currently trying to treat individuals without good population evidence. So I guess flipping a coin is harmless?

[@rpinter677]

Based on the comments I''m concerned that your viewers may draw an incorrect conclusion from your presentation ie beta blockers are useless for all patients. Many patients benefit in terms of rate control, suppression of certain arrhythmias, heart failure, adjunct to other antihypertensives. Carvedilol is a great add on in patients with difficult to control BP.

[@patrickmurray2340]

Unfortunately some people always draw incorrect conclusions. I thought something to glean from this is almost all interventions who's evidence was gathered when patient population was different ie smoking more, less obese, or where advancements have been outstanding need new randomized control trials to measure effecacy.

[@danielmccarthyy]

I bet VP does not take a statin

[@newfguy1826]

as you gain wisdom with advancing age, you will learn to refrain from careless labeling of people as "idiots" or having done a "lousy job" without more careful consideration of others rationale

[@kathleendellavia7862]

Vinay you’re treading in dangerous territory

[@olympiashorts]

Holy hell! No beta blockers and no aspirin? Cats and dogs living together! I’m going to take up smoking now. The world is upside down

[@jamesharcombe45]

Someone should be buying you a beer!

[@mballer]

Old News, no death rate benefit, just another study. Go get some exercise. Doctors love drugs and ignore food. Show me a written prescription for food, exercise and sunshine. Most doctors are lost.

[@sl4983]

And sleep.

[@mballer]

@@sl4983 Food, exercise and sunshine should induce a good sleep. Leave it up to doctors and they'd prescribe a drug for sleep.

[@sl4983]

@@mballer That sounds so simplistic and idealistic. Sometimes a med is needed.

[@mballer]

@@sl4983 Are you serious?

[@sl4983]

@@mballer Are you a doctor??

[@mishu3271]

Hi Vinay. Brilliant as always. I am a person with reduced EF at 40% just re- assessed yesterday by Canadian cardiologist. I asked him to review all factors because I have been CHF/afib ( improved by two cardiac ablations, one surgical error resulting in a hole in my heart) for 5 yrs now. His answer? More drugs! Ramipril. Appt with Electrocardiologist Monday and will ask the same questions. For him particularly can I stop warfarin? This is a very large teaching hospital with a huge Cardiac Care Centre that does research. If these two specialists fail at interpreting the research data in the best interest of the patient where does that leave me? Thank you for mentioning Entresto as I feel strongly that I was deleteriously affected by its longer term use including retina damage and high risk of glaucoma (see medical groups that were concerned about Entresto to FDA - includes opthamologists.) among other side effects.

[@rpinter677]

You have a much more complex situation than the people in the study. Ramipril is not a beta blocker and is a first line drug for CHF. Warfarin is for reducing stroke risk in atrial fibrillation. If you're on continuous heart rhythm monitoring the electrophysiologist will be able to determine your stroke risk with and without the warfarin.

[@mishu3271]

@@rpinter677 Very limited access to the electrocardiologist. No continuous monitoring is done for any reason that I’m aware of. Post surgery two week holter is maximum. Severe chemical allergies can revert me easily to afib…even antibiotics…a new drug is a crap shoot. If ablation #3 required it would be minimum 1-1/2 yr wait. Most likely more. There would be no monitoring if warfarin discontinued. Problematic esp since first blood clot was in my heart after at least a year of mismanagement by a different cardiologist. After 5 years of swimming upstream I am seriously considering medical tourism approach.