ATLANTA — Predischarge initiation of β-blocker therapy in patients with heart failure and left ventricular systolic dysfunction halved mortality during the next 60–90 days among 5,791 patients in a registry, Dr. Gregg C. Fonarow reported at the annual meeting of the American College of Cardiology.
Inpatient initiation of β-blocker therapy should be considered a standard of care in heart failure, said Dr. Fonarow, professor of medicine at the University of California, Los Angeles, and director of the Ahmanson-UCLA Cardiomyopathy Center. The treatment has all the elements of an ideal clinical performance measure, yet it wasn't included among the five inpatient performance measures for adults with chronic heart failure recently issued by an ACC/American Heart Association (AHA) task force (J. Am. Coll. Cardiol. 2005;46:1144–78). The issue deserves to be revisited, he said.
He reported on 5,791 heart failure patients in 91 U.S. hospitals enrolled in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry. Of the 53% with left ventricular systolic dysfunction, 90% were eligible for β-blocker therapy at discharge. Of those, 84% were actually discharged on a β-blocker, and 93% of those remained on the drug at 60− to 90-day follow-up.
Postdischarge 60− to 90-day all-cause mortality was 11.1% in patients eligible for β-blocker therapy who weren't discharged on it, with a combined rate of death or rehospitalization of 42%. Multivariate analysis showed that discharge on a β-blocker was associated with a highly significant 49% reduction in all-cause mortality and a 28% reduction in death or rehospitalization, compared with rates in the eligible-but-untreated group.
Dr. Fonarow stressed that when he and his coinvestigators applied the five ACC/AHA performance measures to the nearly 6,000-patient OPTIMIZE-HF cohort, none predicted 60- to 90-day mortality. Only one—discharge on an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ARB)—was associated with a significant reduction in the combined death or rehospitalization end point. (The other indicators are evaluation of left ventricular systolic function, issuance of discharge instructions, smoking cessation advice/counseling, and discharge anticoagulation for heart failure patients with atrial fibrillation.)
The OPTIMIZE-HF experience undercuts the ACC/AHA task force's assumptions that few stable HF patients would qualify for β-blockade, Dr. Fonarow said in an interview. “Here in OPTIMIZE-HF are the actual prospective data showing that a large number of patients qualify for β-blocker therapy, the tolerability is phenomenal, and it's the most important measure with respect to outcome prediction in terms of death and rehospitalization. So if you were to ask in terms of actual data what would be the most important performance measure for heart failure at the time of discharge, it would be β-blocker therapy, followed by ACE inhibitor/ARBs,” he said. The other measures don't address the highest-priority issues, he added.
Task force member Dr. Kim A. Eagle, clinical director of the University of Michigan Cardiovascular Center, Ann Arbor, said in an interview that it's unclear whether the group will reconsider adding inpatient β-blocker therapy as a heart failure performance indicator. There is a concern that starting the therapy before a patient is stabilized can have adverse consequences, he explained.
OPTIMIZE-HF is funded by GlaxoSmithKline. Last year the registry was incorporated into AHA's ongoing Get With The Guidelines-Heart Failure project.