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Abstract & Commentary
Synopsis: The pre-discharge initiation of beta blocker therapy for decompensated heart failure patients increased the number of patients on beta blockers at 60 days without an increase in length of stay or adverse effects.
Source: Gattis WA, et al. J Am Coll Cardiol. 2004;43: 1534-1541.
Beta blockers are of proven benefit for the long-term management of heart failure, but current guidelines suggest that they should not be started during hospitalization for heart failure decompensation. Thus, Gattis and coworkers conducted the Initiation Management Pre-discharge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial to study whether in patients admitted for heart failure and stabilized, carvedilol initiation predischarge would result in more patients treated with beta blockers at 60 days post-discharge without increasing length of stay or adverse effects. In 45 centers across the United States, 363 patients were randomized to pre-discharge carvedilol vs usual care, which meant beta blocker initiation within 2 weeks after discharge. All had left ventricular ejection fraction < 0.40 and had no contraindications to beta blockers, including class IV status. Carvedilol could be started whenever feasible during hospitalization, but not after 12 hours before discharge. Those in the outpatient beta blocker group could be put on any beta blocker any time deemed appropriate by their physician. The primary end point of the study was the number of patients treated with any beta blocker 60 days after randomization. Several secondary end points were pre-specified. At 60 days, 91% of patients randomized to carvedilol pre-discharge were on beta blockers vs 73% of the usual care patients (P < .001). Also, pre-dischargepatients were more likely to be at target doses of beta blocker (36 vs 28%; P = .02). About 10% of the early and late beta blocker groups had therapy discontinued. Hospital length of stay was not affected. Finally, a composite clinical outcome score was similar for both groups, but there was a trend toward lower death and re-hospitalization in the early initiation group. Gattis et al concluded that the pre-discharge initiation of beta blocker therapy for decompensated heart failure patients increased the number of patients on beta blockers at 60 days without an increase in length of stay or adverse effects.
Comment by Michael H. Crawford, MD
One of the reasons beta blocker use in heart failure patients is generally < 50% is that there is concern about the potential for short-term worsening of heart failure. Although the concern is legitimate, data show that 80-90% of patients will tolerate beta blockers long term. However, to avoid problems the drug manufacturers and current guidelines recommend cautious outpatient titration in very stable patients only. Gattis et al in this study believe that this has stifled the use of this highly beneficial therapy. Thus, the important finding in this study is that in-hospital initiation of therapy results in more longer-term use without an increase in adverse effects.
Of note, these were sick patients. Not only were these patients admitted for heart failure decompensation, but they were discharged relatively early (5 days) and before they had experienced any significant decrease in congestion as estimated by weight. Also, the 60-day death or re-hospitalization rate was 25%.
The study increased the use of beta blockers in the usual care group as well since the rate of 73% is much higher than that reported in other surveys. Thus, it is not surprising that little difference in outcome was seen between the 2 groups. Gattis et al point out that these were the so-called "wet and warm" patients; volume overloaded, but not in a low output state. Those needing isotropic support were excluded.
There were limitations to the study. Although prospective, it was not blinded, but it is not clear how any biases influenced the results other than increasing beta blocker use in the usual care group. Also, the study only evaluated the patients after 60 days of follow-up. It is conceivable that after 6 months or a year, beta blocker use might have been the same, abrogating the value of starting early. Despite these limitations, the study fits with the growing trend to start all beneficial cardiac drugs as early as possible. Decompensated heart failure patients seem to be the last group to move toward the more aggressive approach we are taking today.
Dr. Crawford, Professor of Medicine, Chief of Clinical Cardiology University of California San Francisco, is Editor of Clinical Cardiology Alert.