Factors influencing long-term heart failure mortality in patients with obstructive hypertrophic cardiomyopathy in Western Sweden: probable dose-related protection from beta-blocker therapy

ObjectiveIn order to avoid effects of referral bias, we assessed risk factors for disease-related mortality in a geographical cohort of patients with hypertrophic obstructive cardiomyopathy (HOCM), and any therapy effect on survival.MethodsDiagnostic databases in 10 hospitals in the West Götaland Region yielded 251 adult patients with HOCM (128 male, 123 female). Case notes were reviewed for clinical data and ECG and ultrasound findings. Beta-blockers were used in 71.3% of patients from diagnosis (median metoprolol-equivalent dose of 125 mg/day), and at latest follow-up in 86.1%; 121 patients had medical therapy alone, 88 short atrioventricular delay pacing and 42 surgical myectomy. Mean follow-up was 14.4±8.9 (mean±SD) years. Primary endpoint was disease-related death, and secondary endpoint heart failure deaths.ResultsThere were 65 primary endpoint events. Independent risk factors for disease-related death on multivariate Cox hazard regression were: female sex (p=0.005), age at diagnosis (p<0.001), outflow gradient ≥50 mm Hg at diagnosis (p=0.036) and at follow-up (p=0.001). Heart failure caused 62% of deaths, and sudden cardiac death 17%. Late independent predictors of heart failure death were: female sex (p=0.003), outflow gradient ≥50 mm Hg at latest follow-up (p=0.032), verapamil/diltiazem therapy (p=0.012) and coexisting hypertension (p=0.031), but not other comorbidities. Neither myectomy nor pacing modified survival, but early and maintained beta-blocker therapy was associated with dose-dependent reduction in disease-related mortality in the multivariate model (p=0.028), and final dose was also associated with reduced heart failure mortality (p=0.008). Kaplan-Meier survival curves analysed in initial dose bands of 0–74, 75–149 and ≥150 mg metoprolol/day showed 10-year freedom from disease-related deaths of 83.1%, 90.7% and 97.0%, respectively (ptrend=0.00008). Even after successful relief of outflow obstruction by intervention, there was survival benefit of metoprolol doses ≥100 mg/day (p=0.01).ConclusionsIn population-based HOCM cohorts heart failure is a dominant cause of death and on multivariate analysis beta-blocker therapy was associated with a dose-dependent cardioprotective effect on total, disease-related as well as heart failure-related mortality.

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Digoxin vs. beta-blocker therapy in atrial fibrillation: analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry

European Heart Journal ◽

10.1093/eurheartj/ehab724.0494 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

W.Y Ding ◽

M Proietti ◽

G Boriani ◽

F Marin ◽

C Blomstrom-Lundqvist ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Beta Blocker ◽

Blocker Therapy ◽

Cox Regression Analysis ◽

Beta Blocker Therapy ◽

All Cause Mortality ◽

Related Hospitalisation

Abstract Background There is a long-standing and unresolved controversy over the effects of digoxin on mortality. Furthermore, there is scarce evidence comparing the use of digoxin to beta-blocker in the general population with atrial fibrillation (AF). In this study, we aimed to evaluate the effects of digoxin over beta-blocker therapy among patients with AF. Methods Patients from the EORP-AF General Long-Term Registry with AF who were treated with either digoxin or beta-blocker were included. All patients were over 18 years old and had documented evidence of AF within 12 months prior to enrolment. The outcomes of interest were all-cause mortality, cardiovascular (CV) mortality, non-CV mortality and number of patients with unplanned hospitalisation (total and AF-related). These were recorded until the last known follow-up available. Results Of 6377 patients, 549 (8.6%) and 5828 (91.4%) were treated with digoxin and beta-blockers, respectively. Patients in the digoxin group were older (73 vs. 71 years, p<0.001) with reduced renal function (eGFR 65.4 vs. 68.7 mL/min/1.73m2, p=0.002), and had (in general) greater burden of comorbidities in terms of chronic kidney disease, chronic obstructive pulmonary disease, heart failure, hypertension and peripheral artery disease. Nonetheless, the use of anticoagulation therapy was comparable between both groups (p=0.112). Over 24 months follow-up, there were 550 (8.6%) all-cause mortality and 1304 (23.6%) patients with unplanned emergency hospitalisation. Digoxin use was associated with increased all-cause mortality (hazard ratio [HR] 1.90 [95% CI, 1.48–2.44]), both from CV and non-CV causes (CV: HR 2.21 [95% CI, 1.49–3.26]); non-CV: HR 1.70 [95% CI, 1.04–2.79]). There was no statistical difference in terms of unplanned emergency hospitalisation (HR 0.99 [95% CI, 0.80–1.21]) and AF-related hospitalisation (HR 0.78 [95% CI, 0.58–1.06]) between both groups. Using multivariable cox regression analysis, digoxin compared to beta-blocker therapy was independently linked to increased all-cause mortality (HR 1.52 [95% CI, 1.11–2.09]) and CV mortality (HR 1.82 [95% CI, 1.11–2.97]), but was not related to non-CV mortality (HR 1.31 [95% CI, 0.71–2.41]), emergency hospitalisation (HR 0.91 [95% CI, 0.71–1.16]) or AF-related hospitalisation (HR 0.88 [95% CI, 0.62–1.24]), after adjustment for known risk factors. Conclusion We demonstrated that the use of digoxin was independently associated with excess all-cause mortality, driven by CV death, but was non-inferior to beta-blocker in terms of preventing unplanned emergency or AF-related hospitalisation, after accounting for important risk factors. FUNDunding Acknowledgement Type of funding sources: None.

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Abstract 115: Beta-blocker Therapy in Cocaine Users With Heart Failure: Insights From an Urban Academic Center

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.115 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Obiora E Egbuche ◽

Axiyan Maihemuti ◽

Valery Effoe ◽

Heather R Millard ◽

Leonard Addae ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Beta Blocker ◽

Left Ventricular ◽

P Value ◽

Blocker Therapy ◽

Beta Blocker Therapy ◽

Study Population ◽

The Mean

Background: Beta-blockers are first line agents for reduction of symptoms, hospitalization and mortality in heart failure patients with reduced ejection fraction (HFrEF). The safety and efficacy of continuous beta-blocker therapy (BBT) in patients who use cocaine remain controversial and available literature is limited. We aimed to evaluate clinical outcomes of BBT among HFrEF patients who use cocaine. Methods: We conducted a retrospective chart review of 90 patients with a diagnosis of heart failure based on ICD9-CM codes and baseline ejection fraction (EF) <40% who tested positive for cocaine on urine toxicology test at the time of index admission. We included patients age 18 or older with at least 3 months of follow up. Baseline EF was obtained from the earliest available echocardiogram report in 2011 and repeat EF was obtained from follow up echocardiogram reports while on BBT. We described baseline patient characteristics, comorbidities and outcomes (change in EF during study period, re-hospitalizations and mortality). Results: In our study population (mean age = 56.1 ± 7.8 years), the mean baseline EF was 24.1% (std=9.0). The mean overall change in EF among patients on continuous BBT was 1.9% (std=14.6; p-value=0.2) over a mean follow-up time of 15.5 months (std=8.6). Thirty-nine percent (n=35, mean follow up=15.7 months) of our study population had a decrease in EF (mean change= -10.6%; std=6.8), 22% (n=20, mean follow up=17.4 months) had no change in EF and 39% (n=35, mean follow up=14.3 months) had an increase in EF (mean change= +14.3%; std=7.5). There was an average of 3.2(std=3.3) re-hospitalizations. Ninety-two percent (n=83) were alive at the end of the study period. Conclusion: Continuous beta-blocker therapy in HFrEF patients who abuse cocaine has variable effects on left ventricular EF. Large observational studies are needed to further elucidate the efficacy and safety of long-term beta-blocker therapy in this population.

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868 Beta2-adrenoceptor mediated genet polymorphism may influence the effects of beta-blocker therapy in the patients with heart failure

European Journal of Heart Failure Supplements ◽

10.1016/s1567-4215(03)90559-5 ◽

2003 ◽

Vol 2 (1) ◽

pp. 185

Author(s):

M METRA ◽

S NODARI ◽

N PEZZALI ◽

D FUMAGALLI ◽

A DEICAS ◽

...

Keyword(s):

Heart Failure ◽

Beta Blocker ◽

Blocker Therapy ◽

Beta Blocker Therapy ◽

Patients With Heart Failure

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543 Effect of beta-blocker therapy to left atrial function in patients with mild to moderate heart failure: comparison metoprolol succinate with carvedilol

European Journal of Heart Failure Supplements ◽

10.1016/s1567-4215(06)80340-1 ◽

2006 ◽

Vol 5 (1) ◽

pp. 119-120

Author(s):

S ARSLAN ◽

M EROL ◽

E BOZKURT ◽

M ACIKEL ◽

F GUNDOGDU ◽

...

Keyword(s):

Heart Failure ◽

Beta Blocker ◽

Left Atrial ◽

Atrial Function ◽

Left Atrial Function ◽

Metoprolol Succinate ◽

Blocker Therapy ◽

Beta Blocker Therapy ◽

Moderate Heart Failure

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P3517Failure to achieve adequate heart rate control in women during therapy optimization

European Heart Journal ◽

10.1093/eurheartj/ehz745.0381 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

V Kutyifa ◽

J W Erath ◽

A Burch ◽

B Assmus ◽

D Bondermann ◽

...

Keyword(s):

Heart Failure ◽

Heart Rate ◽

Beta Blocker ◽

Rate Control ◽

Beta Blockers ◽

Heart Rate Control ◽

Blocker Therapy ◽

Cardioverter Defibrillator ◽

Beta Blocker Therapy ◽

The Mean

Abstract Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR <70 bpm at the end of the 3 months. Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58–75). The mean nighttime heart rate was 72 bpm (IQR 65–81) at the beginning of WCD use, that decreased to 68 bpm (IQR 61–76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Figure 1 Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

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