Researchers presented and published two major studies of heart disease outcomes at the ESC Congress of the European Society of Cardiology over the weekend with strikingly different findings. In the REBOOT study, scientists found that beta blockers have no effect on outcomes when given to patients after a heart attack. None. People might be better off with a placebo.

In the other big study, the finding was that semaglutide or tirzepatide can cut the risk of an early death in heart failure with preserved ejection fraction (HFpEF) by half. Likewise, it cuts the risk of hospitalization for the condition. These are dramatic benefits.

These are somewhat different patient populations, though there may be some overlap. The heart attack patients may become heart failure patients. The HFpEF patients may have had a heart attack.

 A Contrast in Access

Another contrast is the availability of the therapies in these two studies. Beta blockers have long been the standard therapy for patients after an MI and pharmacies hand them out like candy with little or no co-pay because they are cheap. But to get coverage for semaglutide and tirzepatide, which are newer and more expensive, providers and patients have to jump mind bendingly absurd hurdles and face delays in therapy because of prior authorization requirements.

If one wanted people to give up on getting an effective therapy, this would be the system they would design.

Setting aside the money at stake, it’s hard not to be appalled by the weight bias at work. Obesity medicine physician Caroline Apovian explained her frustrations:

“For years we’ve been trying to educate physicians about problems with weight gain from beta blockers – which are unnecessary after an uncomplicated myocardial infarction [heart attack]. Causing weight gain, these are not harmless drugs. But the harm of these drugs causing weight gain was not even mentioned in the REBOOT study publication. People overlook it or blame the patient.

“The maddening irony is that many of these patients have easy access to beta blockers which don’t help, while gaining coverage for GLP-1s, which could keep them out of the hospital, is quite difficult.”

Maddening indeed. If pharmacy benefit managers truly worked for the health of patients, the current situation would be turned on its head. Irrational use of beta blockers would face constraints, while GLP-1s would be readily available to save lives and prevent hospitalizations for heart patients.

Click here for the study of semaglutide and tirzepatide in JAMA and here for the REBOOT study of beta blockers in NEJM. For further perspective, click here and here.

Immaculate Heart of Mary, painting by Leopold Kupelwieser, photographed by Diana Ringo, licensed under CC BY-SA 4.0