Low Utilization of Beta-Blockers Among Medicare Beneficiaries Hospitalized for Heart Failure With Reduced Ejection Fraction

Introduction: Heart failure(HF) is a clinical syndrome that is widely prevalent affecting approximately 6.5 million people in the United States. It accounts for the ever-rising health care costs in the US due to recurrent hospitalizations. Despite advancements in medical management, the mortality and the rate of hospitalizations continues to be high with geographic variations and racial disparities. Through this descriptive study, we sought to analyze the health disparities among Hispanic, African American (AA) and Caucasian population in a single-center. Methods: We identified a total of 178 patients with HF with reduced ejection fraction from our outpatient clinic by utilizing the ICD-10 codes. Patients with ejection fraction >50% have been excluded. A retrospective chart review of their ethnic background, medications, and number of heart failure exacerbations per year has been performed. Results: 178 patients (mean age 62 years, 35.56% of females) including Hispanics (n=102), AA(n=44), and Caucasians (n=32) were included in the study. Although all patients were started on Beta-blockers, only 76.4% and 37.2% of Hispanics were started on ACEi/ARBs and spironolactone respectively. Similarly, 72.7% and 45.4% of AA were started on ACEi/ARBs and spironolactone respectively. This is in contrast to Caucasians population, where a majority of patients were on started on GDMT; 90% and 75% were started on ACEi/ARBs and spironolactone respectively. This was also reflected by the number of admissions due to HF exacerbations which ranged from 2-4/year for Hispanics and AA populations and 0-1/year for Caucasians. Conclusions: GDMT for HF is known to reduce heart failure exacerbations, mortality and the ever rising cost of the healthcare system. We have observed that despite recommendations to initiate GDMT in all patients with HF with reduced ejection fraction, racial disparities exist. Physicians should be mindful of initiating GDMT in all patients.

Download Full-text

Targeting Endothelial Function to Treat Heart Failure with Preserved Ejection Fraction: The Promise of Exercise Training

Oxidative Medicine and Cellular Longevity ◽

10.1155/2017/4865756 ◽

2017 ◽

Vol 2017 ◽

pp. 1-17 ◽

Cited By ~ 21

Author(s):

Andreas B. Gevaert ◽

Katrien Lemmens ◽

Christiaan J. Vrints ◽

Emeline M. Van Craenenbroeck

Keyword(s):

Heart Failure ◽

Endothelial Dysfunction ◽

Exercise Training ◽

Ejection Fraction ◽

Current Knowledge ◽

Beta Blockers ◽

Preserved Ejection Fraction ◽

Cellular Mechanisms ◽

Converting Enzyme Inhibitors ◽

Reduced Ejection Fraction

Although the burden of heart failure with preserved ejection fraction (HFpEF) is increasing, there is no therapy available that improves prognosis. Clinical trials using beta blockers and angiotensin converting enzyme inhibitors, cardiac-targeting drugs that reduce mortality in heart failure with reduced ejection fraction (HFrEF), have had disappointing results in HFpEF patients. A new “whole-systems” approach has been proposed for designing future HFpEF therapies, moving focus from the cardiomyocyte to the endothelium. Indeed, dysfunction of endothelial cells throughout the entire cardiovascular system is suggested as a central mechanism in HFpEF pathophysiology. The objective of this review is to provide an overview of current knowledge regarding endothelial dysfunction in HFpEF. We discuss the molecular and cellular mechanisms leading to endothelial dysfunction and the extent, presence, and prognostic importance of clinical endothelial dysfunction in different vascular beds. We also consider implications towards exercise training, a promising therapy targeting system-wide endothelial dysfunction in HFpEF.

Download Full-text

HFrEF pharmacological treatment: ivabradine

ESC CardioMed ◽

10.1093/med/9780198784906.003.0427_update_001 ◽

2018 ◽

pp. 1863-1867

Author(s):

Michel Komajda

Keyword(s):

Heart Failure ◽

Clinical Trial ◽

Heart Rate ◽

Chronic Heart Failure ◽

Ejection Fraction ◽

Sinus Rhythm ◽

Pharmacological Treatment ◽

Beta Blockers ◽

Reduced Ejection Fraction ◽

Background Therapy

Ivabradine slows down the heart rate through a blockade of the funny current channels in the sinoatrial node cells. The efficacy of the drug was tested in a large outcome clinical trial in stable chronic heart failure with reduced ejection fraction, in sinus rhythm, on a contemporary background therapy including beta blockers.

Download Full-text

P1666Do beta-blockers increase the risk for hospitalizations in heart failure with preserved ejection fraction? A secondary analysis of beta-blocker use in the TOPCAT trial

European Heart Journal ◽

10.1093/eurheartj/ehz748.0424 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

D N Silverman ◽

T B Plante ◽

M I Infeld ◽

S P Juraschek ◽

G Dougherty ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Beta Blocker ◽

Proportional Hazards ◽

Beta Blockers ◽

Secondary Analysis ◽

Cox Proportional Hazards ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

Reduced Ejection Fraction

Abstract Background The use of beta-blockers for treatment of heart failure (HF) with a reduced ejection fraction (EF) is unequivocally beneficial, but their role in the treatment of preserved EF (HFpEF) remains unclear. Purpose In a contemporary HFpEF cohort, we sought to assess the association of HF hospitalizations and the use of beta-blockers in patients with an EF above and below 50%. Methods The TOPCAT trial tested spironolactone vs. placebo among patients with HFpEF, including some with mild reductions in EF between 45–50%. The primary outcome was a composite of cardiovascular (CV) mortality, aborted cardiac arrest, or HF hospitalizations. Medication use, including beta-blockers, was reported at each visit and hospitalization. In the 1,761 participants from the Americas, we compared the association of beta-blocker use (vs. no use) and HF hospitalization or CV mortality using Cox proportional hazards models adjusted for baseline demographics, history of myocardial infarction, atrial fibrillation, chronic obstructive pulmonary disease, asthma, and hypertension. The analyses were repeated in the EF strata ≥50% and <50%. Results Among patients included in the current analysis (mean age 72 years, 50% female, 78% white), 1,496/1,761 (85%) received beta-blockers and 1,566/1,761 (89%) had an EF ≥50%. HF hospitalizations and CV mortality occurred in 399/1,761 (23%) and 223/1,761 (13%) of participants, respectively. Beta-blocker use was associated with an increase in risk of HF hospitalization among patients with preserved EF ≥50% [HR 1.56, (95% CI 1.09–2.24), p=0.01] and was associated with a reduction in risk of hospitalization in patients with an EF <50% [HR 0.42, (95% CI 0.18- 0.99), p<0.05]. We found a significant interaction for EF threshold and beta-blocker use on incident HF hospitalizations (p=0.01). There were no differences in CV mortality. Figure 1. Kaplan Meier incidence plots Conclusions Beta-blocker use was associated with an increase in HF hospitalizations in patients with HFpEF (EF≥50%) but did not affect CV mortality. Further research is needed to confirm these findings and elucidate causality.

Download Full-text

Genetic Variation of Hepatic Enzymes Influence on β-Blocker Dose in Patients With Reduced Ejection Fraction Heart Failure

Journal of Pharmacy Practice ◽

10.1177/0897190018782794 ◽

2018 ◽

Vol 33 (1) ◽

pp. 96-98

Author(s):

Adam Ingram ◽

Megan Valente

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Treatment Guidelines ◽

Beta Blockers ◽

African Ancestry ◽

Genetic Variations ◽

Hepatic Enzymes ◽

Active Metabolites ◽

Reduced Ejection Fraction ◽

Heart Failure Patients

Beta-blockers such as metoprolol, carvedilol, and bisoprolol are indicated for the treatment of patients with reduced ejection fraction heart failure. Heart failure treatment guidelines call for titration of these medications to specific target doses for morbidity and mortality benefit. Hepatic enzymes are responsible for metabolizing these medications; however, these enzymes are subject to genetic variations (polymorphisms) that can increase or decrease enzyme activity. Metoprolol relies almost exclusively on this enzyme for degradation to inactive metabolites, whereas carvedilol relies on this enzyme only partially for metabolism, and the portion of drug that is metabolized by CYP2D6 becomes active metabolites. The clinical significance of genetic variations in CYP2D6 in heart failure patients requiring treatment with carvedilol and metoprolol remains unclear, and further research is needed before any strong recommendations on treatment approach can be made. However, based on what is known regarding the incidence of genetic variations of this enzyme, it is reasonable to conclude that heart failure patients of European and Asian ancestry may be at a greater risk of intolerance to guideline-directed doses of metoprolol. Patients of North African ancestry may be at a lower risk of intolerance to metoprolol, although limited data are available to conclude. Additionally, due to the significant prevalence of CYP2D6 enzyme variations among all ethnicities, it may be reasonable to consider switching to carvedilol for patients who are unable to fully titrate metoprolol.

Download Full-text

SO057BETA-BLOCKERS ARE ASSOCIATED WITH REDUCED MORTALITY IN PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION AND ADVANCED CHRONIC KIDNEY DISEASE: COHORT STUDY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa139.so057 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Edouard L Fu ◽

Alicia Uijl ◽

Friedo W Dekker ◽

Lars H Lund ◽

Gianluigi Savarese ◽

...

Keyword(s):

Heart Failure ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Ejection Fraction ◽

Beta Blocker ◽

Beta Blockers ◽

Advanced Chronic Kidney Disease ◽

Reduced Ejection Fraction ◽

Patients With Heart Failure ◽

All Cause Mortality

Abstract Background and Aims Beta-blockers reduce mortality and morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, patients with advanced chronic kidney disease (CKD) were underrepresented in landmark trials. We evaluated if beta-blockers are associated with improved survival in patients with HFrEF and advanced CKD. Method We identified 3906 persons with an ejection fraction <40% and advanced CKD (eGFR <30 mL/min/1.73m2) enrolled in the Swedish Heart Failure Registry during 2001-2016. The associations between beta-blocker use, 5-year all-cause mortality, and the composite of time to cardiovascular (CV) mortality/first HF hospitalization were assessed by multivariable Cox regression. Analyses were adjusted for 36 variables, including demographics, laboratory measures, comorbidities, medication use, medical procedures, and socioeconomic status. To assess consistency, the same analyses were performed in a positive control cohort of 12,673 patients with moderate CKD (eGFR <60-30 mL/min/1.73m2). Results The majority (89%) of individuals with HFrEF and advanced CKD received treatment with beta-blockers. Median (IQR) age was 81 (74-86) years, 36% were women and median eGFR was 26 (20-28) mL/min/173m2. During 5 years of follow-up, 2086 (53.4%) individuals had a subsequent HF hospitalization, and 2954 (75.6%) individuals died, of which 2089 (70.1%) due to cardiovascular causes. Beta-blocker use was associated with a significant reduction in 5-year all-cause mortality [adjusted hazard ratio (HR) 0.86; 95% confidence interval (CI) 0.76-0.96)] and CV mortality/HF hospitalization (HR 0.87; 95% CI 0.77-0.98). The magnitude of the associations between beta-blocker use and outcomes was similar to that observed for HFrEF patients with mild/moderate CKD, with adjusted HRs for all-cause mortality and CV mortality/HF hospitalization of 0.85 (95% CI 0.78-0.91) and 0.88 (95% CI 0.82-0.96), respectively. Conclusion Despite lack of trial evidence, the use of beta-blockers in patients with HFrEF and advanced CKD was high in routine Swedish care, and was independently associated with reduced mortality to the same degree as HFrEF with moderate CKD.

Download Full-text

Evidence-based beta blocker use associated with lower heart failure readmission and mortality, but not all-cause readmission, among Medicare beneficiaries hospitalized for heart failure with reduced ejection fraction

PLoS ONE ◽

10.1371/journal.pone.0233161 ◽

2020 ◽

Vol 15 (7) ◽

pp. e0233161

Author(s):

Matthew Shane Loop ◽

Melissa K. Van Dyke ◽

Ligong Chen ◽

Todd M. Brown ◽

Raegan W. Durant ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Beta Blocker ◽

Evidence Based ◽

Medicare Beneficiaries ◽

Reduced Ejection Fraction

Download Full-text

Network Meta-Analysis to Assess Comparative Effectiveness of Beta-Blockers in Patients with Heart Failure and Reduced Ejection Fraction

Value in Health ◽

10.1016/j.jval.2015.09.780 ◽

2015 ◽

Vol 18 (7) ◽

pp. A375

Author(s):

S Aggarwal ◽

H Topaloglu ◽

S Kumar

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Comparative Effectiveness ◽

Beta Blockers ◽

Meta Analysis ◽

Reduced Ejection Fraction ◽

Patients With Heart Failure

Download Full-text

THE HEMODYNAMIC EFFECTS OF INTRAVENOUS MILRINONE THERAPY IN HEART FAILURE WITH REDUCED EJECTION FRACTION PATIENTS ON BETA-BLOCKERS

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(18)31329-9 ◽

2018 ◽

Vol 71 (11) ◽

pp. A788

Author(s):

David Tehrani ◽

Sara Kalantari ◽

Jonathan Grinstein ◽

Nitasha Sarswat ◽

Jayant Raikhelkar ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Beta Blockers ◽

Hemodynamic Effects ◽

Reduced Ejection Fraction

Download Full-text

«Grey zone» of heart failure

Kazan medical journal ◽

10.17816/kmj2018-651 ◽

2018 ◽

Vol 99 (4) ◽

pp. 651-656

Author(s):

P Yu Galin ◽

S A Kulbaisova ◽

N Erov

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Beta Blockers ◽

Research Work ◽

Epidemiological Studies ◽

Response To Treatment ◽

Grey Zone ◽

Preserved Ejection Fraction ◽

Aldosterone Antagonists ◽

Reduced Ejection Fraction

The review is devoted to modern understanding of heart failure with mid-range ejection fraction. The formation of the paradigm of «two phenotypes» of heart failure began around the end of the last century. As a result of a number of large epidemiological studies on heart failure with preserved ejection fraction, so-called «grey zone» of ejection fraction values was formed in the range of about 40-50%. This situation arose because of the lack of clearly established level of normal ejection fraction and underlines imperfection of this parameter as the only classification criterion. But no more convenient «tool» for research work was offered. In the past decade, «grey zone» of heart failure has been actively explored by clinical epidemiologists and clinicians. Should we classify these patients as one of the existing phenotypes of heart failure or present them as a new, separate phenotype? Both the first and second decisions require information about the population «portrait» of subgroup, about their response to treatment, and presumptive pathophysiological mechanisms of heart failure. In 2016 European society of cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure, heart failure with mid-range ejection fraction was determined as a separate subgroup to stimulate the search for such data. At the moment mid-range ejection fraction is known to be recorded in about 10-20% of patients with heart failure. They have substantial comorbidities as patients with preserved ejection fraction but the prevalence of ischemic heart disease in this subgroup makes it similar to heart failure with reduced ejection fraction. The response to treatment with beta-blockers and aldosterone antagonists is similar to that of heart failure with reduced ejection fraction. It is important that the mortality rates in all three groups of patients are approximately the same. This circumstance underlines the importance of further searche. Perhaps the research of «grey zone» of the syndrome will help to better understand pathophysiology of the existing heart failure phenotypes and confirm the validity of their identification based on ejection fraction.

Download Full-text