β-Blocker at Discharge Cuts HF Mortality by Half : Despite the positive outcomes, the therapy isn't part of the ACC/AHA inpatient performance measures.


ATLANTA — Predischarge initiation of β-blocker therapy in patients with heart failure and left ventricular systolic dysfunction halved mortality during the next 60–90 days among 5,791 patients in a registry, Dr. Gregg C. Fonarow reported at the annual meeting of the American College of Cardiology.

Inpatient initiation of β-blocker therapy ought to be considered a standard of care in heart failure management, according to Dr. Fonarow, professor of medicine at the University of California, Los Angeles, and director of the Ahmanson-UCLA Cardiomyopathy Center.

The treatment has all the elements of an ideal clinical performance measure for use in quality improvement and pay-for-performance programs.

And yet it was not included among the five inpatient performance measures for adults with chronic heart failure that were recently published by an ACC/American Heart Association (AHA) task force. That is an oversight, and the issue deserves to be revisited, Dr. Fonarow said.

He reported on 5,791 heart failure patients in 91 U.S. hospitals who comprised a prespecified subgroup with prospective follow-up among enrollees in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry.

Of the 53% who had left ventricular systolic dysfunction, 90% were deemed eligible for β-blocker therapy at discharge. And of those eligible, 84% were actually discharged on a β-blocker, and 93% of those remained on the drug at 60- to 90-day follow-up.

Postdischarge 60- to 90-day all-cause mortality in patients eligible for β-blocker therapy who weren't discharged on it was 11.1%, with a combined rate of death or rehospitalization of 42%.

A risk-adjusted multivariate analysis showed that discharge on a β-blocker was associated with a highly significant 49% reduction in all-cause mortality and a 28% reduction in death or rehospitalization, compared with rates in the eligible-but-untreated group.

Dr. Fonarow stressed that when he and his coinvestigators applied the five recently published ACC/AHA performance measures to the OPTIMIZE-HF cohort of nearly 6,000 patients, none of the five predicted 60- to 90-day mortality, and only one—discharge on an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ARB)—was associated with a significant reduction in the combined death or rehospitalization end point.

In addition to discharge on an ACE inhibitor or ARB, the other current ACC/AHA inpatient performance indicators are the evaluation of left ventricular systolic function, the issuance of discharge instructions, smoking cessation advice/counseling, and discharge anticoagulation for heart failure patients with atrial fibrillation.

The ACC/AHA task force considered including β-blockade as an inpatient performance measure but elected not to on the grounds that “the complexities of establishing the right conditions under which stable HF patients would be included in the measure minus the exclusions would result in so small a denominator that the measure would not be meaningful at this time” (J. Am. Coll. Cardiol. 2005;46:1144–78). But this was an assumption not based on data—and the OPTIMIZE-HF experience undercuts the task force's rationale, Dr. Fonarow said in an interview.

“Here in OPTIMIZE-HF are the actual prospective data showing that a large number of patients qualify for β-blocker therapy, the tolerability is phenomenal, and it's the most important measure with respect to outcome prediction in terms of death and rehospitalization.

“So if you were to ask in terms of actual data what would be the most important performance measure for heart failure at the time of discharge, it would be β-blocker therapy, followed by ACE inhibitor/ARBs,” he said.

Although the other current performance measures may be important in terms of long-term care, the finding that they do not improve 60- to 90-day mortality or rehospitalization means they do not address the highest priority issues, Dr. Fonarow continued.

Task force member Dr. Kim A. Eagle, the clinical director of the University of Michigan Cardiovascular Center, Ann Arbor, said in an interview that it is unclear whether the group will reconsider adding inpatient β-blocker therapy as a heart failure performance indicator.

There is a concern that starting the therapy too early—before a patient is stabilized—can have adverse consequences, he added.

The OPTIMIZE-HF registry is funded by GlaxoSmithKline. Last year, the registry was incorporated into AHA's ongoing Get With The Guidelines-Heart Failure project.

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