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Jamil Y, Park DY, Verde LM, Sherwood MW, Tehrani BN, Batchelor WB, Frampton J, Damluji AA, Nanna MG. Do Clinical Outcomes and Quality of Life Differ by the Number of Antianginals for Stable Ischemic Heart Disease? Insights from the BARI 2D Trial. Am J Cardiol 2024; 214:66-76. [PMID: 38160927 PMCID: PMC10923116 DOI: 10.1016/j.amjcard.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/21/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
Medical therapy, including antianginal treatment, is the cornerstone in the management of stable ischemic heart disease (SIHD). However, it remains unclear whether combining antianginal agents provides benefits beyond monotherapy in terms of quality of life (QoL) and cardiovascular outcomes. We used data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, which compared cardiovascular and QoL outcomes in patients with SIHD and diabetes mellitus randomized to revascularization with intensive medical therapy or intensive medical therapy alone. We categorized patients into 3 groups: ≥2 versus 1 versus 0 antianginals. We compared patient characteristics, QoL metrics, and cardiovascular end points at baseline and at 5 years, creating a multivariable model to adjust for key clinical confounders. Of 2,368 patients, 348 patients (14.7%) were on 0 antianginals, 1,020 patients (43.1%) were on 1 antianginal, and 1,000 patients (42.2%) were on ≥2 antianginals at baseline. The most common antianginal class was β blockers. At baseline, patients on 0 antianginals had better QoL metrics (self-health score, Duke activity status index, and energy rating) than patients on ≥2 antianginals. However, at the 1-year follow-up, patients taking only 1 antianginal showed greater QoL improvement than those taking 0 antianginal, without any incremental benefit in QoL metrics seen in patients taking ≥2 antianginal agents, even after adjusting for multiple covariates such as age, heart failure, diabetes control, and myocardial jeopardy index. Lastly, at the 5-year follow-up, after adjustment, there were no differences in all-cause mortality, major adverse cardiovascular events, or myocardial infarction between patients taking different numbers of antianginals. Adults on a single antianginal for SIHD and diabetes mellitus had similar or better improvements in QoL than those on 2 or more antianginal agents at 1 year of follow-up. These findings merit further research to better understand the impact of medical therapy intensity on QoL in patients with SIHD and associated co-morbidities.
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Affiliation(s)
- Yasser Jamil
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
| | - Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Luis More Verde
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Falls Church, Virginia; Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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Sotomi Y, Hikoso S, Nakatani D, Okada K, Dohi T, Sunaga A, Kida H, Sato T, Matsuoka Y, Kitamura T, Komukai S, Seo M, Yano M, Hayashi T, Nakagawa A, Nakagawa Y, Tamaki S, Ohtani T, Yasumura Y, Yamada T, Sakata Y. Medications for specific phenotypes of heart failure with preserved ejection fraction classified by a machine learning-based clustering model. Heart 2023; 109:1231-1240. [PMID: 36822821 PMCID: PMC10423528 DOI: 10.1136/heartjnl-2022-322181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE Our previously established machine learning-based clustering model classified heart failure with preserved ejection fraction (HFpEF) into four distinct phenotypes. Given the heterogeneous pathophysiology of HFpEF, specific medications may have favourable effects in specific phenotypes of HFpEF. We aimed to assess effectiveness of medications on clinical outcomes of the four phenotypes using a real-world HFpEF registry dataset. METHODS This study is a posthoc analysis of the PURSUIT-HFpEF registry, a prospective, multicentre, observational study. We evaluated the clinical effectiveness of the following four types of postdischarge medication in the four different phenotypes: angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB), beta blockers, mineralocorticoid-receptor antagonists (MRA) and statins. The primary endpoint of this study was a composite of all-cause death and heart failure hospitalisation. RESULTS Of 1231 patients, 1100 (83 (IQR 77, 87) years, 604 females) were eligible for analysis. Median follow-up duration was 734 (398, 1108) days. The primary endpoint occurred in 528 patients (48.0%). Cox proportional hazard models with inverse-probability-of-treatment weighting showed the following significant effectiveness of medication on the primary endpoint: MRA for phenotype 2 (weighted HR (wHR) 0.40, 95% CI 0.21 to 0.75, p=0.005); ACEi or ARB for phenotype 3 (wHR 0.66 0.48 to 0.92, p=0.014) and statin therapy for phenotype 3 (wHR 0.43 (0.21 to 0.88), p=0.020). No other medications had significant treatment effects in the four phenotypes. CONCLUSIONS Machine learning-based clustering may have the potential to identify populations in which specific medications may be effective. This study suggests the effectiveness of MRA, ACEi or ARB and statin for specific phenotypes of HFpEF. TRIAL REGISTRATION NUMBER UMIN000021831.
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Affiliation(s)
- Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuki Matsuoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiro Seo
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Japan
| | | | - Akito Nakagawa
- Division of Cardiology, Amagasaki Chuo Hospital, Amagasaki, Japan
| | - Yusuke Nakagawa
- Division of Cardiology, Kawanishi City Medical Center, Kawanishi, Japan
| | - Shunsuke Tamaki
- Department of Cardiovascular Medicine, Rinku General Medical Center, Izumisano, Japan
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshio Yasumura
- Division of Cardiology, Amagasaki Chuo Hospital, Amagasaki, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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Musse M, Lau JD, Yum B, Pinheiro LC, Curtis H, Anderson T, Steinman MA, Meyer M, Dorsch M, Hummel SL, Goyal P. Physician Perspectives on the Use of Beta Blockers in Heart Failure With Preserved Ejection Fraction. Am J Cardiol 2023; 193:70-74. [PMID: 36878055 PMCID: PMC10114214 DOI: 10.1016/j.amjcard.2023.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 03/07/2023]
Abstract
β-blockers are commonly used in heart failure with preserved ejection fraction (HFpEF), even in the absence of a compelling indication and despite the potential to cause harm. Identifying reasons for β-blocker prescription in HFpEF could permit the development of strategies to reduce unnecessary use and potentially improve medication prescribing patterns in this vulnerable population. We administered an online survey regarding β-blocker prescribing behavior to physicians trained in internal medicine or geriatrics (noncardiology physicians) and to cardiologists at 2 large academic medical centers. The survey assessed the reasons for β-blocker initiation, agreement regarding initiation and/or continuation of β-blockers by another clinician, and deprescribing behavior. The response rate was 28.2% (n = 231). Among respondents, 68.2% reported initiating β-blockers in patients with HFpEF. The most common reason for initiating a β-blocker was for treatment of an atrial arrhythmia. Notably, 23.7% of physicians reported initiating a β-blocker without an evidence-based indication. When a β-blocker was considered not necessary, 40.1% of physicians reported they were rarely or never willing to deprescribe. The most common reason for not deprescribing a β-blocker when the physician felt that a β-blocker was unnecessary was the concern about interfering with another physicians' treatment plan (76.6%). In conclusion, a significant proportion of noncardiology physicians and cardiologists report prescribing β-blockers to patients with HFpEF, even when evidence-based indications are absent, and rarely deprescribe β-blockers in these scenarios.
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Affiliation(s)
- Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jennifer D Lau
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Brian Yum
- Texas Heart Institute, Houston, Texas
| | - Laura C Pinheiro
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Hannah Curtis
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Timothy Anderson
- Division of General Medicine, Beth Israel Deaconess, Boston, Massachusetts
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Michael Dorsch
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Scott L Hummel
- University of Michigan Frankel Cardiovascular Center; VA Ann Arbor Health System, Ann Arbor, Michigan
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York.
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Bertomeu-Gonzalez V, Moreno-Arribas J, Heras S, Fernandez-Ortiz N, Cazorla D, Quintanilla MA, Lopez-Ayala JM, Facila L, Zuazola P, Cordero A. Increased Risk of Heart Failure in Elderly Patients Treated with Beta-Blockers After AV Node Ablation. Am J Cardiovasc Drugs 2023; 23:157-164. [PMID: 36652190 PMCID: PMC10006059 DOI: 10.1007/s40256-022-00566-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Controversy exists regarding the indication of beta-blockers (BB) in different scenarios in patients with cardiovascular disease. We sought to evaluate the effect of BB on survival and heart failure (HF) hospitalizations in a sample of pacemaker-dependent patients after AV node ablation to control ventricular rate for atrial tachyarrhythmias. METHODS A retrospective study including consecutive patients that underwent AV node ablation was conducted in a single center between 2011 and 2019. The study's primary endpoints were the incidence of all-cause mortality, first HF hospitalization and the cumulative incidence of subsequent hospitalizations for HF. Competing risk analyses were employed. RESULTS A total of 111 patients with a mean age of 73.9 years were included in the study. After a median follow-up of 45.5 months, 43 patients had died (38.7%) and 31 had been hospitalized for HF (27.9%). The recurrent HF hospitalization rate was 74/1000 patients/year. Patients treated with BB had a non-significant trend to higher mortality rates and a higher risk of recurrent HF hospitalizations (incidence rate ratio 2.23, 95% confidence interval 1.12-4.44; p = 0.023). CONCLUSION After an AV node ablation, the use of BB is associated with an increased risk of HF hospitalizations in a cohort of elderly patients.
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Affiliation(s)
- Vicente Bertomeu-Gonzalez
- Cardiology Department, Hospital Clinica Benidorm, Benidorm, Spain.
- Department of Clinical Medicine, Miguel Hernandez University, Universidad Miguel Hernández de Elche, Ctra Valencia-Alicante S/N, 03550, San Juan de Alicante, Alicante, Spain.
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | - Jose Moreno-Arribas
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Santiago Heras
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Nerea Fernandez-Ortiz
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Diego Cazorla
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - María Amparo Quintanilla
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Jose Maria Lopez-Ayala
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Lorenzo Facila
- Cardiology Department, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
- Universitat de Valencia, Valencia, Spain
| | - Pilar Zuazola
- Department of Clinical Medicine, Miguel Hernandez University, Universidad Miguel Hernández de Elche, Ctra Valencia-Alicante S/N, 03550, San Juan de Alicante, Alicante, Spain
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Alberto Cordero
- Department of Clinical Medicine, Miguel Hernandez University, Universidad Miguel Hernández de Elche, Ctra Valencia-Alicante S/N, 03550, San Juan de Alicante, Alicante, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiology Department, Hospital Universitario de San Juan de Alicante, San Juan de Alicante, Alicante, Spain
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5
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Wheeler MT, Jacoby D, Elliott PM, Saberi S, Hegde SM, Lakdawala NK, Myers J, Sehnert AJ, Edelberg JM, Li W, Olivotto I. Effect of beta-blocker therapy on the response to mavacamten in patients with symptomatic obstructive hypertrophic cardiomyopathy. Eur J Heart Fail 2023; 25:260-270. [PMID: 36404399 DOI: 10.1002/ejhf.2737] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/28/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS In the EXPLORER-HCM trial, mavacamten improved exercise capacity and symptoms in patients with obstructive hypertrophic cardiomyopathy (oHCM). Mavacamten effects on the primary endpoint, a composite of peak oxygen consumption (VO2 ) and New York Heart Association (NYHA) class, were greater in patients not receiving background beta-blockers than in those receiving beta-blockers. We sought to determine if the effect of background treatment was consistent across other clinically meaningful parameters. METHODS AND RESULTS Subgroup analyses by beta-blocker use were performed in patients with oHCM from the EXPLORER-HCM and mavacamten long-term extension (MAVA-LTE) studies. In EXPLORER-HCM, 189 patients (75.3%) were receiving beta-blockers, and 62 (24.7%) were receiving non-dihydropyridine calcium channel blockers or no background HCM medication; 170 patients (90.4%) receiving beta-blockers had chronotropic incompetence. Improvements in peak VO2 at week 30 with mavacamten versus placebo were lower with beta-blockers (mean difference [95% confidence interval (CI)]: 1.04 [0.12, 1.95] ml/kg/min) than without beta-blockers (mean difference [95% CI]: 2.69 [1.29, 4.09] ml/kg/min); improvements in non-heart rate-dependent parameters (VE /VCO2 slope) appeared unaffected by beta-blockers. Improvements in functional capacity parameters at week 30 with mavacamten versus placebo were independent of beta-blockade for post-exercise left ventricular outflow tract gradient (mean difference [95% CI]: -37.9 [-48.0, -27.9] mmHg with beta-blockers; -33.5 [-53.6, -13.3] mmHg without beta-blockers), proportion of patients with reduction of ≥1 NYHA class, Kansas City Cardiomyopathy Questionnaire clinical summary scores and N-terminal pro-B-type natriuretic peptide. Mavacamten benefits were reproduced and maintained in MAVA-LTE regardless of beta-blockade. CONCLUSION Mavacamten improved measures of functional capacity, left ventricular outflow tract obstruction, symptom burden and biomarkers in patients with HCM regardless of beta-blocker use. Beta-blocker use was often associated with chronotropic incompetence, affecting peak VO2 and other heart rate-dependent measures, but had minimal impact on heart rate-independent measures.
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Affiliation(s)
- Matthew T Wheeler
- Division of Cardiovascular Medicine, Center for Inherited Cardiovascular Disease, Stanford University, Stanford, CA, USA
| | - Daniel Jacoby
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Perry M Elliott
- University College London & St. Bartholomew's Hospital, London, UK
| | - Sara Saberi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sheila M Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neal K Lakdawala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Myers
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford University, Palo Alto, CA, USA
| | - Amy J Sehnert
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Jay M Edelberg
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Wanying Li
- MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb, Brisbane, CA, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unity, Azienda Ospedaliera Universitaria Careggi and University of Florence, Florence, Italy
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Beta-Blocker Use in Hypertension and Heart Failure (A Secondary Analysis of the Systolic Blood Pressure Intervention Trial). Am J Cardiol 2022; 165:58-64. [PMID: 34906366 PMCID: PMC8766945 DOI: 10.1016/j.amjcard.2021.10.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 11/20/2022]
Abstract
Given the concern that beta-blocker use may be associated with an increased risk for heart failure (HF) in populations with normal left ventricular systolic function, we evaluated the association between beta-blocker use and incident HF events, as well as loop diuretic initiation in the Systolic Blood Pressure Intervention Trial (SPRINT). SPRINT demonstrated that a blood pressure target of <120 mm Hg reduced cardiovascular outcomes compared with <140 mm Hg in adults with at least one cardiovascular risk factor and without HF. The lower rate of the composite primary outcome in the 120 mm Hg group was primarily driven by a reduction in HF events. Subjects on a beta blocker for the entire trial duration were compared with subjects who never received a beta blocker after 1:1 propensity score matching. A competing risk survival analysis by beta-blocker status was performed to estimate the effect of the drug on incident HF and was then repeated for a secondary end point of cardiovascular disease death. Among the 3,284 propensity score-matched subjects, beta-blocker exposure was associated with an increased HF risk (hazard ratio 5.86; 95% confidence interval 2.73 to 13.04; p <0.001). A sensitivity analysis of propensity score-matched cohorts with a history of coronary artery disease or atrial fibrillation revealed the same association (hazard ratio 3.49; 95% confidence interval 1.15 to 10.06; p = 0.028). In conclusion, beta-blocker exposure in this secondary analysis was associated with increased incident HF in subjects with hypertension without HF at baseline.
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Joo SJ, Kim SY, Choi JH, Park HK, Beom JW, Lee JG, Chae SC, Kim HS, Kim YJ, Cho MC, Kim CJ, Rha SW, Yoon J, Jeong MH. Effect of beta-blocker therapy in patients with or without left ventricular systolic dysfunction after acute myocardial infarction. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:475-482. [DOI: 10.1093/ehjcvp/pvaa029] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/07/2020] [Accepted: 04/08/2020] [Indexed: 11/12/2022]
Abstract
Abstract
Aims
This observational study aimed to investigate the association between beta-blocker therapy and clinical outcomes in patients with acute myocardial infarction (AMI), especially with mid-range or preserved left ventricular systolic function.
Methods and results
Among 13 624 patients enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH), 12 200 in-hospital survivors were selected. Patients with beta-blockers showed significantly lower 1-year major adverse cardiac events (MACE), which was a composite of cardiac death, MI, revascularization, and readmission due to heart failure [9.7 vs. 14.3/100 patient-year; hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.72–0.97; P = 0.022). However, this association had a significant interaction with left ventricular ejection fraction (LVEF). Beta-blocker therapy at discharge was associated with lower 1-year MACE in patients with LVEF ≤40% (HR 0.63, 95% CI 0.48–0.81; P < 0.001), and 40% <LVEF < 50% (HR 0.69, 95% CI 0.51–0.94; P = 0.020), but not in patients with LVEF ≥50% (HR 1.16, 95% CI 0.91–1.48; P = 0.234).
Conclusions
Beta-blocker therapy at discharge was associated with better 1-year clinical outcomes in patients with reduced or mid-range LVEF after AMI, but not in patients with preserved LVEF. These data suggested that the long-term beta-blocker therapy may be guided by LVEF.
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Affiliation(s)
- Seung-Jae Joo
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Song-Yi Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Joon-Hyouk Choi
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Hyeung Keun Park
- Department of Health Policy and Management, Jeju National University School of Medicine, Republic of Korea
| | - Jong Wook Beom
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Jae-Geun Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Jo Kim
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Chong Jin Kim
- Department of Internal Medicine, Kyunghee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Junghan Yoon
- Department of Internal Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Myung Ho Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
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8
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Beta-Blocker Cessation in Stable Outpatients With Heart Failure With a Preserved Ejection Fraction. J Card Fail 2020; 26:281-282. [DOI: 10.1016/j.cardfail.2019.08.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/29/2019] [Accepted: 08/15/2019] [Indexed: 11/18/2022]
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9
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Silverman DN, Plante TB, Infeld M, Callas PW, Juraschek SP, Dougherty GB, Meyer M. Association of β-Blocker Use With Heart Failure Hospitalizations and Cardiovascular Disease Mortality Among Patients With Heart Failure With a Preserved Ejection Fraction: A Secondary Analysis of the TOPCAT Trial. JAMA Netw Open 2019; 2:e1916598. [PMID: 31800067 PMCID: PMC6902757 DOI: 10.1001/jamanetworkopen.2019.16598] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE β-Blockers are prescribed to most patients with heart failure (HF) with a preserved ejection fraction (HFpEF), but their effect on HFpEF remains unclear. OBJECTIVE To determine the association of β-blocker use with HF hospitalizations and cardiovascular disease (CVD) mortality, overall and in strata of patients with an ejection fraction (EF) of 50% or greater or less than 50%. DESIGN, SETTING, AND PARTICIPANTS For 1761 participants from North and South America enrolled in the multicenter, double-blinded Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist randomized clinical trial of spironolactone for patients with HFpEF between August 10, 2006, and January 31, 2012, the association of baseline β-blocker use with HF hospitalization and CVD mortality was analyzed using unadjusted and adjusted Cox proportional hazards regression models, overall and in strata of patients with an EF of 50% or greater or less than 50%. Participants had symptomatic HF with a left ventricular EF of 45% or greater, with enrollment based on either hospitalization attributed to decompensated HF in the prior year or elevated natriuretic peptide levels. Statistical analysis was performed from January 31 to May 2, 2019. EXPOSURE Use of β-blockers. MAIN OUTCOMES AND MEASURES Incident HF hospitalization and CVD mortality. RESULTS Among 1761 participants included in the analysis (879 women and 882 men; mean [SD] age, 71.5 [9.6] years), 1394 (79.2%) reported β-blocker use and 1567 (89.0%) had an EF of 50% or greater. Hospitalizations for HF occurred for 399 participants (22.7%), and CVD mortality occurred for 229 participants (13.0%). Use of β-blockers was associated with a higher risk of HF hospitalization among patients with HFpEF with an EF of 50% or greater (hazard ratio, 1.74 [95% CI, 1.28-2.37]; P < .001) but not among patients with an EF between 45% and 49% (hazard ratio, 0.68 [95% CI, 0.28-1.63]; P = .39). There was a significant interaction between β-blocker use and EF threshold for incident HF hospitalizations (P = .03). Use of β-blockers was not associated with a change in CVD mortality. CONCLUSIONS AND RELEVANCE For patients with an EF of 50% or greater, β-blocker use was associated with an increased risk of HF hospitalizations but not CVD mortality. For patients with an EF between 45% and 49%, there was no such association.
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Affiliation(s)
- Daniel N. Silverman
- Department of Medicine and Biostatistics Unit, Larner College of Medicine, University of Vermont, Burlington
| | - Timothy B. Plante
- Department of Medicine and Biostatistics Unit, Larner College of Medicine, University of Vermont, Burlington
| | - Margaret Infeld
- Department of Medicine and Biostatistics Unit, Larner College of Medicine, University of Vermont, Burlington
| | - Peter W. Callas
- Department of Medicine and Biostatistics Unit, Larner College of Medicine, University of Vermont, Burlington
| | - Stephen P. Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Geoff B. Dougherty
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Markus Meyer
- Department of Medicine and Biostatistics Unit, Larner College of Medicine, University of Vermont, Burlington
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Wahlberg K, Arnold ME, Lustgarten D, Meyer M. Effects of a Higher Heart Rate on Quality of Life and Functional Capacity in Patients With Left Ventricular Diastolic Dysfunction. Am J Cardiol 2019; 124:1069-1075. [PMID: 31395299 DOI: 10.1016/j.amjcard.2019.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/21/2019] [Accepted: 07/02/2019] [Indexed: 01/23/2023]
Abstract
There is no evidence-based treatment for heart failure with preserved ejection fraction. Although lower heart rates (HRs) provide an unequivocal benefit for patients with HF with reduced ejection fraction, higher HR might convey important hemodynamic and substrate-modifying benefits in patients with diastolic dysfunction. In a prospective study of 20 stable outpatients with diastolic dysfunction and pacemakers, we evaluated the effects of a 4-week increase in the lower pacemaker rate to 80 beats/min followed by reversal to the previous lower HR setting from weeks 4 to 6. We assessed quality of life (Minnesota Living with Heart Failure Questionnaire), 6-minute walk test and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. Pacing at 80 beats/min significantly improved quality of life and the 6-minute walk test (p ≤0.05). There was a strong positive correlation between the pacing-induced changes in NT-proBNP and baseline QRS intervals (r2 = 0.31, p <0.01). Stratification by QRS duration revealed that pacing at 80 beats/min led to -21 ± 26% reduction in NT-proBNP in patients with QRS ≤150 ms, whereas QRS >150 ms was associated with a 26 ± 35% increase in NT-proBNP (p <0.01). Patients physiologically paced from the conduction system had a -46 ± 26% reduction in NT-proBNP at 80 beats/min as compared with 4 ± 26% and 13 ± 26% change with pacing from the right atrial appendage and right ventricular apical septum (pinteraction = 0.04). In conclusion, increasing the lower rate setting of pacemakers to 80 beats/min in patients with diastolic dysfunction improves quality of life, functional capacity, and NT-proBNP for those patients with a baseline QRS ≤150 ms. These findings suggest that higher HRs may provide meaningful benefits to patients with left ventricular diastolic dysfunction and heart failure with preserved ejection fraction.
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Affiliation(s)
- Kramer Wahlberg
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont.
| | - Maren E Arnold
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Daniel Lustgarten
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Markus Meyer
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont
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11
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Meyer M, LeWinter MM. Heart Rate and Heart Failure With Preserved Ejection Fraction: Time to Slow β-Blocker Use? Circ Heart Fail 2019; 12:e006213. [PMID: 31525068 DOI: 10.1161/circheartfailure.119.006213] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Markus Meyer
- Cardiology Unit, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington
| | - Martin M LeWinter
- Cardiology Unit, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington
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