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Antihypertensives and myocardial infarction risk: the modifying effect of history of drug use

Authors

  • Chantal Bourgault PhD,

    1. Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
    2. Pharmacoepidemiology Research Unit, Division of Clinical Epidemiology, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
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  • Eleanor Elstein MD,

    1. Department of Medicine, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
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  • Marc A. Baltzan MD, MSc,

    1. Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
    2. Pharmacoepidemiology Research Unit, Division of Clinical Epidemiology, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
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  • Jacques Le Lorier MD PhD,

    1. Centre de recherche de l'Hôtel-Dieu de Montréal, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
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  • Samy Suissa PhD

    Corresponding author
    1. Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
    2. Pharmacoepidemiology Research Unit, Division of Clinical Epidemiology, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
    • Division of Clinical Epidemiology, Royal Victoria Hospital (MUHC), 687 Pine avenue West, Ross 4.29, Montreal, Quebec, Canada, H3A 1A1.
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Abstract

Purpose

Confounding by indication is common in observational studies of outcomes that treatment is intended to affect. In light of the stepped-care approach to hypertension management, we reexamined the controversy around myocardial infarction (MI) risk in relation to antihypertensive agents by considering past drug history both as a confounder and as an effect modifier.

Methods

Case–control design nested within a cohort of 19 501 adults initiating therapy with angiotensin-converting enzyme inhibitors (ACEI), calcium channel blockers (CCB) or β-blockers in Saskatchewan (1990–93) and followed up to 1997. MI cases were identified using death certificates and hospital discharge diagnoses (ICD-9 410). Four controls were matched to each case to account for duration and timing of follow-up.

Results

812 MI cases were identified, of which 26% were fatal. At first, current use of CCB and ACEI (versus β-blockers) appeared to be associated with an increased risk of MI (RR = 2.2; 95% CI = 1.8–2.7 and RR = 1.3; CI = 1.0–1.6 respectively). Adjustment for drug use history attenuated both associations (RR = 1.6; CI = 1.1–2.2 and RR = 1.0; CI = 0.7–1.4). Moreover, the risk for CCB use disappeared when restricted to patients who had already used these agents in the past (RR = 1.1; CI = 0.77–1.7) whereas a high risk of MI for ACEI was found in digoxin users (RR = 9.4; CI = 3.2–27.5).

Conclusion

Past drug history can be both a confounder and an effect modifier in observational studies. We found adjustment for medication history to attenuate the associations between antihypertensive agents and MI risk. In addition, the estimates significantly varied across drug history profiles thus suggesting the presence of preferential prescribing of specific drug classes to high-risk patients. Copyright © 2001 John Wiley & Sons, Ltd.

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