Ninety-day mortality and readmission rates are significantly lower for older patients with heart failure and reduced ejection fraction when they receive a beta-blocker after hospitalization.1

“People with heart failure who take beta-blockers live longer and are less likely to be readmitted than people who don’t,” says Lauren Gilstrap, MD, MPH, assistant professor of cardiology at Dartmouth-Hitchcock Medical Center in Lebanon, NH. Gilstrap also is an assistant professor of healthcare policy at Dartmouth University’s Geisel School of Medicine.

“The magnitude of benefits also do not decrease with age,” Gilstrap adds. “These therapies should be tried in people admitted for heart failure [unless there is a strong clinical indication otherwise].”

Regular heart failure education also is critical. This is where case managers can help.

It is crucial for patients to learn how to monitor their salt and fluid intake and when to call their provider if their weight begins to increase, Gilstrap says. Case managers also can reinforce the provider’s information about common medication side effects and what issues and changes they should look for.

“It requires an ongoing relationship with patients,” Gilstrap says. “This is where case managers come in, because heart failure is a chronic disease, and it requires an ongoing, continuous conversation between the patient, their family, the care manager, and the physician.”

It is much easier to handle little problems than to wait until they become bigger problems. The more case managers and providers communicate with patients, the sooner they will know about health issues related to their heart condition.

“We need to educate them about standard heart failure management and anticipated side effects,” Gilstrap says.

Case managers can show patients how to advocate for themselves, and for their families to advocate for them as well. “We need to put all the tools in place and encourage our patients to communicate with us, but on some level, they need to take a degree of responsibility,” Gilstrap says. “My case managers call every patient with heart failure within three days of discharge. The most important thing they do is medication reconciliation — figuring out who is doing the medications is key.”

Case managers also ensure any medication changes are filled, the pills are affordable, and that the patient can access them. Case managers also ask patients how they are doing and whether they are experiencing swelling, shortness of breath, or weight gain. They make sure patients know their follow-up appointments and will see their providers within 14 days.

“We try to set them up to see a [provider] close to home. If the care manager is worried based on their conversation with a patient, then we call the primary care provider office and help get them an [earlier] appointment,” Gilstrap explains. “When [this case management system] works the way it is supposed to work, it helps with early intervention; the sooner you deal with it, the easier it is going to be to solve.”

Beta-blockers and angiotensin-converting enzyme (ACE) inhibitors are important for heart failure patients, but there are side effects and risks. “The potential side effects of these two classes of drugs increase as people get older and frailer, and as they acquire other comorbidities, particularly kidney disease,” Gilstrap explains.

The question Gilstrap and colleagues investigated was whether heart failure patients hit a tipping point, based on their age and frailty, in which the risks of side effects of these drugs outweighed the potential benefits.

“We want to do the right thing for somebody from a heart failure perspective, but we don’t want to expose them to the risks,” Gilstrap adds. “Side effects are low heart rate and passing out, which can be extremely dangerous for older folks.”

A main adverse event with ACE inhibitors is kidney failure/problems. Gilstrap and colleagues found the benefit of beta-blockers did not appear to wane with age, and all patients with heart failure should attempt beta-blocker therapy at discharge, regardless of age, unless there is a strong contraindication.

Older patients appear to benefit as much from the beta-blocker therapy as younger patients. “The reality is, the 85-year-olds benefited just as much as the 65-year-olds,” Gilstrap says.

REFERENCE

  1. Gilstrap L, Austin AM, O’Malley AJ, et al. Association between beta-blockers and mortality and readmission in older patients with heart failure: An instrumental variable analysis. J Gen Intern Med 2021;36:2361-2369.