Influence of Beta - Blocker

Continuation or Withdrawal on Outcomes in Patients Hospitalized With Heart Failure

Journal of the American College of Cardiology Vol. 52, No. 3, 2008Fonarow et al.

S. Nadery, MCH 2008

Vragen en opmerkingen graag bewaren tot aan einde van deze presentatie

Introduction One

Heart failure (HF) highly lethal Mortality 25% to 45% ( rst year) fi 1.1 million/ year U.S.; primary cause

hospitalizations 2.4 to 3.6 million hospitalizations

contributing factor Previous studies showed:

Certain beta-blockers Reduced 35 % mortality

National guidlines

Introduction Two

Continuation or withdrawn of beta -blocker

Hospitalization and before admission OPTIMIZE - HF (Organized Program to Initiate Lifesaving

Treatment in Hospitalized Patients with Heart Failure)

Large, representative cohort study

Methods

Study design

March 2003 - December 2004 Inclusion criteria:

New episode HF Worsening HF Significant HF symptoms develops

of another primary diagnosis Exclusion criteria:

Contraindication Intolerance

Statistical analysis

Pearson chi-square test: Categorical variables

Kruskal-Wallis test: Continuous variables

Propensity score and Multivariable adjustment: Relationship ß-blocker and

outcome

Results one

Total enrollment: 48,612 patients from 259 hospitals

Confined: 5,791 patients from 91 hospitals

Pre-specified 60- to 90-day post-discharge follow-up

From 5,791 patients: In 5,117 pts LVF assessed In 2,720 pts LVSD documented

Further details Table 1

Result two

Result three

HF before admission 89.3 % Medication on admission:

Beta blockers 57 % ACE inhibitor 47 % Angiotensin receptor blocker 12 % Aldosterone antagonist 10 % Digoxin 30 %

Hospitalized duration mean 6.4 days (median 5 days)

Result four

From 2,720 pts: 2,373 (87.2 %) eligible for ß-blocker therapy 347 (12.8 %) ineligible (contraindication

or intolerance) From 2,373 pts eligible for

ß-blocker therapy: 1,350 (56.9 %) continued on ß-B 79 (3.3 %) withdrawn 303 (12.8 %) not treated 632 (26.6 %) newly started 9 (0.4 %) missing data

Result five

Among 1,537 patients receiving beta-blocker therapy before hospital presentation: 1,350 (87.8%) continued on beta-

blocker therapy 187 (12.2%) withdrawn (108 with

documented contraindications or intolerance and 79 without) LVEF was lower

Result six

ß-Blocker use and clinical outcomes

Result eight

Click hyperlinks or please move to PDF file Figure 1

Tolerability

Therapy Continuation Group: 93.6 % remaining of ß-Blocker

Therapy Newly Starting Group: 91.9 % remaining of ß-Blocker

Therapy Not Prescribed Group: 23.9 % started ß-Blocker OR 46.7, CI 32 to 68, p. 0.0001

Therapy Withdrawn Group: 56.5 % restarted ß-Blocker OR 11.3, CI 6.5 to 19, p. 0.0001

Discussion one

OPTIMIZE-HF program: In uence of continuation and withdrawal fl

of beta-blocker therapy Registry contains: characteristics,

presenting symptoms, treatments, and outcomes

Continuation of beta- blocker therapy: lower risk.

Withdrawal of beta-blockers associated: excess adjusted mortality risk.

Continuation of beta- blocker therapy: well tolerated

Discussion two

Decision of discontinue BB: Greater state of decompensation may account for poor outcomes Abrupt cessation of BB associated:

Ischemia Hypertension Ventricular arrhythmias Myocardial infarction

No reason(s) collected for decisions In some case contraindication and

intolerance not documented Interpretation of results subject to

limitation (not a RCT)

Discussion three

LVEF in Withdrawn Group: Lower (21.7 %, p. 0.0001)

Serum creatinine high High exp. post-discharge mortality DM 60 to 90-days post-discharge

mortality vs mortality and/or rehospitalization

And ….

Gregg C. Fonarow, William T. Abraham, Nancy M. Albert, Wendy Gattis Stough, Mihai Gheorghiade Barry H. Greenberg, Christopher M. O’Connor, Jie Lena Sun, Clyde W. Yancy, James B. Young,

Conclusions

Continuation of beta-blocker therapy among patients hospitalized with HF is associated with better outcomes than those in whom beta-blocker therapy is withdrawn or never initiated.

Questions?