Patterns of beta-blocker intensification in ambulatory heart failure patients and short-term association with hospitalization

BMC Cardiovascular Disorders

Frederick A Masoudi²  David W Brand³  Susan Shetterly³  Christina L Clarke³  Pamela N Peterson¹  Chan Zeng³  David J Magid³  Larry A Allen² 

[1]Division of Cardiology, Denver Health Medical Center, Denver, CO, USA

[2]Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

[3]Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA

关键词: Outcomes;    Safety;    Beta-blocker (β-blocker);    Pharmacology;    Heart failure;   

Others  :  1084897
DOI  :  10.1186/1471-2261-12-43

 received in 2011-10-27, accepted in 2012-06-18,  发布年份 2012

【 摘 要 】

Background

In response to the short-term negative inotropic and chronotropic effects of β-blockers, heart failure (HF) guidelines recommend initiating β-blockers at low dose with gradual uptitration as tolerated to doses used in clinical trials. However, patterns and safety of β-blocker intensification in routine practice are poorly described.

Methods

We described β-blocker intensification among Kaiser Colorado enrollees with a primary discharge diagnosis of HF between 2001–2009. We then assessed β-blocker intensification in the 30 days prior to first hospital readmission for cases compared to the same time period following index hospitalization for non-rehospitalized matched controls. In separate analysis of the subgroup initiated on β-blocker after index hospital discharge, we compared adjusted rates of 30-day hospitalization following initiation of high versus low dose β-blocker.

Results

Among 3,227 patients, median age was 76 years and 37% had ejection fraction ≤40% (LVSD). During a median follow up of 669 days, 14% were never on β-blocker, 21% were initiated on β-blocker, 43% were discharged on β-blocker but never uptitrated, and 22% had discharge β-blocker uptitrated; 63% were readmitted and 49% died. β-blocker intensification occurred in the 30 days preceding readmission for 39 of 1,674 (2.3%) readmitted cases compared to 27 (1.6%) of matched controls (adjusted OR 1.36, 95% CI 0.81-2.27). Among patients initiated on therapy, readmission over the subsequent 30 days occurred in 6 of 155 (3.9%) prescribed high dose and 9 of 513 (1.8%) prescribed low dose β-blocker (adjusted OR 3.10, 95% CI 1.02-9.40). For the subgroup with LVSD, findings were not significantly different.

Conclusion

While β-blockers were intensified in nearly half of patients following hospital discharge and high starting dose was associated with increased readmission risk, the prevailing finding was that readmission events were rarely preceded by β-blocker intensification. These data suggest that β-blocker intensification is not a major precipitant of hospitalization, provided recommended dosing is followed.

【 授权许可】

   
2012 Allen et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW: Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009, 114:e391-e479.
• [2]Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010, 16:e1-e194.
• [3]Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Stromberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, Swedberg K, Vahanian A, Camm J, De Caterina R, Dean V, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL: ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 2008, 29:2388-2442.
• [4]Fonarow GC, Heywood JT, Heidenreich PA, Lopatin M, Yancy CW: Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004: findings from Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J 2007, 153:1021-1028.
• [5]Mann DL: “Pathophysiology of Heart Failure. “Braunwald’s Heart disease. In A Textbook of Cardiovascular Medicine. Edited by Bonow RO, Mann DL, Zipes DP, Libby P. Saunders, Philadelphia; 2011:487.
• [6]Lechat P, Packer M, Chalon S, Cucherat M, Arab T, Boissel JP: Clinical effects of beta-adrenergic blockade in chronic heart failure: a meta-analysis of double-blind, placebo-controlled, randomized trials. Circulation 1998, 98:1184-1191.
• [7]Gattis WA, O'Connor CM, Gallup DS, Hasselblad V, Gheorghiade M: Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial. J Am Coll Cardiol 2004, 43:1534-1541.
• [8]Krum H, Roecker EB, Mohacsi P, Rouleau JL, Tendera M, Coats AJ, Katus HA, Fowler MB, Packer M: Effects of initiating carvedilol in patients with severe chronic heart failure: results from the COPERNICUS Study. JAMA 2003, 289:712-718.
• [9]Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O'Connor CM, Sun JL, Yancy CW, Young JB: Dosing of beta-blocker therapy before, during, and after hospitalization for heart failure (from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure). Am J Cardiol 2008, 102:1524-1529.
• [10]Peterson PN, Shetterly SM, Clarke CL, Bekelman DB, Chan PS, Allen LA, Matlock DD, Magid DJ, Masoudi FA: Health literacy and outcomes among patients with heart failure. JAMA 2011, 305:1695-1701.
• [11]Go AS, Yang J, Ackerson LM, Lepper K, Robbins S, Massie BM, Shlipak MG: Hemoglobin level, chronic kidney disease, and the risks of death and hospitalization in adults with chronic heart failure: the Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) Study. Circulation 2006, 113:2713-2723.
• [12]Go AS, Yang J, Gurwitz JH, Hsu J, Lane K, Platt R: Comparative effectiveness of beta-adrenergic antagonists (atenolol, metoprolol tartrate, carvedilol) on the risk of rehospitalization in adults with heart failure. Am J Cardiol 2007, 100:690-696.
• [13]Go AS, Lee WY, Yang J, Lo JC, Gurwitz JH: Statin therapy and risks for death and hospitalization in chronic heart failure. JAMA 2006, 296(17):2105-2111.
• [14]Chaudhry SI, Wang Y, Concato J, Gill TM, Krumholz HM: Patterns of weight change preceding hospitalization for heart failure. Circulation 2007, 116:1549-1554.