Effectiveness of Beta- blockers in Heart Failure
Effectiveness of Beta- blockers in Heart Failure
Abstract & Commentary
By Harold L. Karpman, MD, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman reports no financial relationship to this field of study.
Synopsis: In elderly patients hospitalized with heart failure and LVSD, beta-blocker use was clinically effective in reducing mortality and rehospitalization, but patients with preserved systolic function had poor outcomes and beta-blockers did not significantly influence the mortality and rehospitalization rate for these patients.
Source: Hernandez AF, et al. Clinical effectiveness of beta-blockers in heart failure: Findings from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) Registry. J Am Coll Cardiol 2009;53:184-192.
Congestive heart failure (CHF) remains the most common hospital discharge diagnosis for Medicare beneficiaries1 and, although outcomes for heart failure are often quite poor, the many advances in our understanding of CHF over the past 2 decades have led to important advances in therapy. One such major advance in therapy among patients with CHF and reduced systolic function has been the use of beta-blockers,2 which have conferred a 10%-40% reduction in mortality and recurrent hospitalizations within 1 year3-5 after discharge following hospitalization for CHF. Although current guidelines have recommended that populations underrepresented in CHF trials, such as elderly patients, women, racial/ethnic minorities, and patients with comorbid conditions, should be treated along the same guidelines as are the patients used in the clinical trials, many physicians have been hesitant to do so without additional evidence of drug effectiveness in these populations.2-5
Because of the limited evidence and the uncertainty of the clinical effectiveness of beta-blockers in elderly patients with heart failure who had been newly initiated on beta-blocker therapy and discharged after a heart failure hospitalization, Hernandez and colleagues examined Medicare claims data and merged them with the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) records in an attempt to examine the long-term outcomes in this group of patients.6 In elderly patients with CHF and left ventricular systolic dysfunction (LVSD), beta-blocker therapy was clinically effective and independently associated with lower risks of death after hospitalization. Patients with preserved systolic function had relatively worse outcomes and beta-blockers did not significantly influence the mortality and rehospitalization risks of these patients.
Commentary
The Hernandez study is interesting because it successfully analyzed the data addressing the clinical effectiveness of beta-blockers in patients with CHF by linking a large contemporary CHF registry containing data on clinical characteristics, treatment eligibility, drug intolerance, and contraindications with long-term outcome data derived from Medicare claims. In essence, the analysis determined that beta-blockers were clinically effective in patients with LVSD, which tends to occur in the population of patients that is usually older and have more comorbid conditions than the participants who are more commonly enrolled in randomized clinical trials. Most important, although patients with preserved left ventricular function were observed to have substantial mortality and morbidity after hospitalization for CHF, patients with LVSD experienced a substantial benefit from beta-blocker therapy in this important cohort of patients. Recognizing that the study was limited because it was observational and that long-term, randomized, controlled trials are clearly needed to establish efficacy of therapy with beta-blockers and/or any other drugs used in patients with and without abnormal left ventricular function on outcomes, the data contained in this study may be of significant importance in developing our understanding regarding the clinical effectiveness of the beta-blockers in patients who are hospitalized for heart failure, especially since additional randomized studies of this nature are not likely to be conducted in the near future because of ethical considerations.
It is important for clinicians to recognize that beta-blockers did not substantially change the risk of death or rehospitalization in patients with CHF and preserved systolic function; in fact, these patients were observed to have relatively poor outcomes in the Hernandez study. On the other hand, in an elderly population hospitalized for CHF, beta-blocker therapy at discharge was associated with significantly improved risk and survival for patients with LVSD, at least in the first year of follow-up and quite possibly over an indefinite period of time, although the study was limited to only 1 year of follow-up.
References
1. Rosamund W, et al. Heart disease and stroke statistics2008 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-e146.
2. Hunt SA, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005;46:e1-e82.
3. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999;353:2001-2007.
4. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): A randomised trial. Lancet 1999;353:9-13.
5. Packer M, et al. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med 2001; 344:1651-1658.
6. Clinical effectiveness of beta-blockers in heart failure: Findings from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) Registry. J Am Coll Cardiol 2009;53:184-192.
In elderly patients hospitalized with heart failure and LVSD, beta-blocker use was clinically effective in reducing mortality and rehospitalization, but patients with preserved systolic function had poor outcomes and beta-blockers did not significantly influence the mortality and rehospitalization rate for these patients.Subscribe Now for Access
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