Abstract 13135: Starting Beta-blockers in Hypertension is Followed by Excess Loop Diuretic Use: Beta-blocker Induced Heart Failure?

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Daniel N Silverman ◽  
Jeanne d de Lavallaz ◽  
Timothy B Plante ◽  
Margaret M Infeld ◽  
Markus Meyer
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Beta Blocker ◽  
Antihypertensive Medication ◽  
Temporal Relationship ◽  
Loop Diuretic ◽  
Beta Blockers ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction

Introduction: Recent investigation has identified that discontinuation of beta-blockers in subjects with normal left ventricular ejection fraction (LVEF) leads to a reduction in natriuretic peptide levels. We investigated whether a similar trend would be seen in a hypertension clinical trial cohort. Methods: In 9,012 subjects hypertensive subjects without a history of symptomatic heart failure, known LVEF <35% or recent heart failure hospitalization enrolled in the Systolic Blood Pressure Intervention Trial (SPRINT), we compared incidence of loop diuretic initiation and time to initiation following start of a new anti-hypertensive medication. The categorical relationship (new antihypertensive class followed by loop-diuretic use) and temporal relationship (time to loop diuretic initiation) were each analyzed. The categorical relationship was assessed using a Pearson’s chi-squared test and the temporal relationship using a Wilcoxon rank sum test. Bonferroni-corrected p-values were utilized for all comparisons. Results: Among the 9,012 subjects analyzed, the incidence of anti-hypertensive initiation and loop diuretic initiation was greatest following start of a beta-blocker (16.6%) compared with other antihypertensive medication classes (calcium channel blocker 13.8%, angiotensin converting enzyme-inhibitor/angiotensin receptor blocker 12.9% and thiazide diuretic 10.2%; p<0.001). In addition, the median time between starting a new antihypertensive medication and loop diuretic was the shortest for beta-blockers and longest for thiazides (both p <0.01). No significant differences in renal function were identified between groups. Conclusion: Compared to other major classes of hypertensive agents, starting beta-blockers was associated with more common and earlier initiation of a loop diuretics in a population without heart failure at baseline. This finding may suggest beta-blocker induced heart failure in a population with a predominantly normal ejection fraction.

scholarly journals Beta-blocker use is associated with prevention of left ventricular remodeling in recovered dilated cardiomyopathy

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
N Enzan ◽  
S Matsushima ◽  
T Ide ◽  
H Kaku ◽  
T Higo ◽  
...  
Keyword(s):  
Left Ventricular Ejection Fraction ◽  
Ejection Fraction ◽  
Beta Blocker ◽  
Primary Outcome ◽  
Protocol Analysis ◽  
Beta Blockers ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Funding Source ◽  
Ventricular Ejection Fraction

Abstract Background Withdrawal of optimal medical therapy has been reported to relapse cardiac dysfunction in patients with dilated cardiomyopathy (DCM) whose cardiac function had improved. However, it is unknown whether beta-blockers can prevent deterioration of cardiac function in those patients. Purpose We examined the effect of beta-blockers on left ventricular ejection fraction (LVEF) in recovered DCM. Methods We analyzed the clinical personal records of DCM, a national database of Japanese Ministry of Health, Labor and Welfare, between 2003 and 2014. Recovered DCM was defined as a previously documented LVEF &lt;40% and a current LVEF ≥40%. Patients with recovered DCM were divided into two groups according to the use of beta-blockers. The primary outcome was defined as a decrease in LVEF &gt;10% at two years of follow-up. A one to one propensity case-matched analysis was used. A per-protocol analysis was also performed. Considering intra- and inter-observer variability of echocardiographic evaluations, we also examined outcomes by multivariable logistic regression model after changing the inclusion criteria as follows; (1) previous LVEF &lt;40% and current LVEF ≥40%; (2) previous LVEF &lt;35% and current LVEF ≥40%; (3) previous LVEF &lt;30% and current LVEF ≥40%; (4) previous LVEF &lt;40% and current LVEF ≥50%. Outcomes were also changed as (1) decrease in LVEF ≥5% (2) decrease in LVEF ≥10% (3) decrease in LVEF ≥15%. The analysis of outcomes by using combination of multiple imputation and inverse probability of treatment weighting was also conducted to assess the effects of missing data and selection bias attributable to propensity score matching on outcomes. Results From 2003 to 2014, 40,794 consecutive patients with DCM were screened. Out of 5,338 eligible patients, 4,078 received beta-blockers. Propensity score matching yielded 998 pairs. Mean age was 61.7 years and 1,497 (75.0%) was male. Mean LVEF was 49.1±8.1%. The primary outcome was observed less frequently in beta-blocker group than in no beta-blocker group (18.0% vs. 23.5%; odds ratio [OR] 0.72; 95% confidence interval [CI] 0.58–0.89; P=0.003). The prevalence of increases in LVDd (11.5% vs. 15.8%; OR 0.70; 95% CI 0.54–0.91; P=0.007) and LVDs (23.1% vs. 27.2%; OR 0.80; 95% CI 0.65–0.99; P=0.041) was also lower in the beta-blocker group. Similar results were obtained in per-protocol analysis. These results were robust to several sensitivity analyses. As a result of preventing a decrease in LVEF, the deterioration to HFrEF was also prevented by the use of beta-blocker (23.6% vs. 30.6%). Subgroup analysis demonstrated that beta-blocker prevented decrease in LVEF regardless of atrial fibrillation. Conclusion Use of beta-blocker was associated with prevention of decrease in left ventricular ejection fraction in patients with recovered DCM. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Health Sciences Research Grants from the Japanese Ministry of Health, Labour and Welfare (Comprehensive Research on Cardiovascular Diseases)

Abstract 398: Use Of Guideline-Directed Medical Therapy For Patients Hospitalized With Heart Failure In The Veterans Health Care System, 2013-2017

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Paul L Hess ◽  
Paula Langner ◽  
Gary K Grunwald ◽  
Paul A Heidenreich ◽  
P. M Ho
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Beta Blocker ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Free Care ◽  
Va Hospitals ◽  
Over Time

Background: Guidelines issued by the American Heart Association and American College of Cardiology recommend the use of key heart failure (HF) medications. Contemporary use of HF medications in Veterans Affairs (VA) hospitals is unknown. Methods: Using national administrative data maintained by the Corporate Data Warehouse, we identified all patients admitted with a primary diagnosis of HF who were discharged from a VA hospital between January 1, 2013, and December 29, 2017, and had a left ventricular ejection fraction ≤ 40% by echocardiography. Left ventricular ejection fraction was extracted from the medical record using natural language processing with high precision and sensitivity. Rates of guideline-directed medical therapy use at hospital discharge were assessed overall and over time. Defect-free care was defined as use of any beta-blocker and an angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or angiotensin receptor neprilysin inhibitor (ARNI). Use of an evidence-based beta-blocker (bisoprolol, carvedilol, or metoprolol succinate) and an aldosterone antagonist were also evaluated. Results: A total of 13,767 patients from 126 sites with HF with reduced ejection fraction underwent 18,769 hospitalizations (1.4 hospitalizations/patient). Their mean age was 70.7 (standard deviation 11.4) years, the predominant sex was male (98.3%), and the principle race/ethnicity was white (67.2%). Defect-free HF care was achieved during 13,941 (74.2%) hospitalizations. A beta-blocker was prescribed during 17,196 (91.6%), and an ACEI, ARB, or ARNI was prescribed during 14,626 (77.9%). An evidence-based blocker was prescribed during 17,057 (90.9%) hospitalizations, and an aldosterone antagonist during 6,934 (36.9%). Defect-free care decreased over time from 76.4% in 2013 to 71.9% in 2017 owing to a reduction in ACEI/ARB/ARNI use from 80.2% in 2013 to 76.0% in 2017. Rates of use of other HF medications were stable over time ( Figure 1 ). Conclusions: The majority of patients hospitalized with heart failure in VA hospitals receive defect-free HF care. However, rates of defect-free HF care have decreased over time. Opportunities to improve the use of HF medical therapy use exist.

Beta-blockers are associated with incident heart failure: a secondary analysis of the systolic blood pressure intervention (SPRINT) trial

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
D.N Silverman ◽  
J.D.F De Lavallaz ◽  
T.B Plante ◽  
P Goyal ◽  
M.M Infeld ◽  
...  
Keyword(s):  
Heart Failure ◽  
Blood Pressure ◽  
Systolic Blood Pressure ◽  
Beta Blocker ◽  
Antihypertensive Medication ◽  
Loop Diuretic ◽  
Beta Blockers ◽  
Left Ventricular ◽  
Sensitivity Analyses ◽  
Funding Source

Abstract Background The Systolic Blood Pressure Intervention Trial (SPRINT) evaluated whether a blood pressure (BP) goal of less than 120mmHg versus less than 140mmHg would reduce cardiovascular outcomes in subjects with at least one cardiovascular risk factor and without heart failure. Participating investigators were encouraged to use any antihypertensive medication class with a strong evidence base. The SPRINT trial was halted early due to a lower rate of the composite primary outcome in the 120mmHg group, which was mainly driven by a reduction in heart failure (HF). Objective As there is a concern that beta-blocker use may be associated with an excess risk for incident HF in subjects with a normal left ventricular systolic function, we evaluated the association between beta-blocker use and HF. Beta-blockers were compared with other major classes of antihypertensive medications. We also studied the association of antihypertensive class with loop-diuretic initiation. Methods and results In the 9,012 subjects, without HF at baseline, the association of beta-blocker exposure and incident HF was examined using time-variant competing risk analysis. Beta-blocker exposure was associated with an increased HF risk (HR 1.18; CI 1.07–1.30; p&lt;0.001) and more frequent and earlier loop diuretic-use compared to other antihypertensive agents (both p&lt;0.01). Sensitivity analyses of propensity-score matched cohorts confirmed a strong association of beta-blocker use and HF. Other major antihypertensive medication classes did not show this association. Conclusions Beta-blocker exposure was associated with a higher incidence of HF in hypertensive subjects without HF at baseline. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health

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