title: Effectiveness comparison of cardio-selective to non-selective β-blockers and their association with mortality and morbidity in end-stage renal disease: a retrospective cohort study.
abstract: BACKGROUND
  Within-class comparative effectiveness studies of β-blockers have not been performed in the chronic dialysis setting. With widespread cardiac disease in these patients and potential mechanistic differences within the class, we examined whether mortality and morbidity outcomes varied between cardio-selective and non-selective β-blockers.
  
  
  METHODS
  Retrospective observational study of within class β-blocker exposure among a national cohort of new chronic dialysis patients (N = 52,922) with hypertension and dual eligibility (Medicare-Medicaid). New β-blocker users were classified according to their exclusive use of one of the subclasses. Outcomes were all-cause mortality (ACM) and cardiovascular morbidity and mortality (CVMM). The associations of cardio-selective and non-selective agents on outcomes were adjusted for baseline characteristics using Cox proportional hazards.
  
  
  RESULTS
  There were 4938 new β-blocker users included in the ACM model and 4537 in the CVMM model: 77 % on cardio-selective β-blockers. Exposure to cardio-selective and non-selective agents during the follow-up period was comparable, as measured by proportion of days covered (0.56 vs. 0.53 in the ACM model; 0.56 vs 0.54 in the CVMM model). Use of cardio-selective β-blockers was associated with lower risk for mortality (AHR = 0.84; 99 % CI = 0.72-0.97, p = 0.0026) and lower risk for CVMM events (AHR = 0.86; 99 % CI = 0.75-0.99, p = 0.0042).
  
  
  CONCLUSIONS
  Among new β-blockers users on chronic dialysis, cardio-selective agents were associated with a statistically significant 16 % reduction in mortality and 14 % in cardiovascular morbidity and mortality relative to non-selective β-blocker users. A randomized clinical trial would be appropriate to more definitively answer whether cardio-selective β-blockers are superior to non-selective β-blockers in the setting of chronic dialysis.
authors.affiliation: Health Services Policy & Practice and the Center for Gerontology & Health Care Research, Brown University School of Public Health, 121 South Main St, Box-G-S121-6, Providence, RI, 02912, USA. theresa_shireman@brown.edu.
authors.forename: Theresa I
authors.initials: TI
authors.lastname: Shireman
authors.affiliation: Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Mahnken
authors.affiliation: Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA.
authors.forename: Milind A
authors.initials: MA
authors.lastname: Phadnis
authors.affiliation: Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City, KS, USA.|Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
authors.forename: Edward F
authors.initials: EF
authors.lastname: Ellerbeck
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000959:Antihypertensive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002423:Cause of Death; D016009:Chi-Square Distribution; D057186:Comparative Effectiveness Research; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008297:Male; D008484:Medicaid; D006278:Medicare; D008875:Middle Aged; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000319:Adrenergic beta-Antagonists; D000959:Antihypertensive Agents
keywords: Comparative effectiveness; Dialysis; End stage renal disease; Hypertension; Mortality; β-blockers