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Experience with beta-blocker therapy in patients with advanced heart failure evaluated for HTx
R Berger1, K Strecker, M Hülsmann
1Department of Cardiology and Ludwig Boltzman Institute of Cardiovascular Research, University of Vienna, Vienna, Austria. RBerger@gmx.at
Insights
Adding beta-blockers to angiotensin-converting enzyme inhibitors (ACE-I) improves survival in advanced heart failure patients awaiting transplantation. For those tolerating this combination, heart transplantation may not offer additional short-term survival benefits.
Area of Science:
- Cardiology
- Pharmacology
- Transplantation Medicine
Background:
- Patients with advanced heart failure evaluated for heart transplantation often receive high-dose angiotensin-converting enzyme inhibitors (ACE-I).
- The role of beta-blocker therapy in addition to ACE-I in this patient population requires further investigation.
- The study questions the necessity of heart transplantation for patients already on combined ACE-I and beta-blocker therapy.
Purpose of the Study:
- To review the experience with beta-blocker therapy on top of high-dose ACE-I in advanced heart failure patients.
- To evaluate the impact of this combined therapy on outcomes, including the need for heart transplantation.
- To assess the survival benefit of heart transplantation in patients receiving optimal medical therapy.
Main Methods:
- Retrospective analysis of 318 advanced heart failure patients (NYHA class III/IV, low LVEF, low cardiac index).
- Patients were treated with digitalis, diuretics, ACE-I, and beta-blockers (if tolerated) or intravenous support.
- Stratification into groups based on ACE-I alone, ACE-I plus beta-blockers, or ACE-I plus intravenous support.
Main Results:
- The group receiving both beta-blockers and ACE-I (Group A) showed significantly lower mortality (9%) compared to ACE-I alone (Group B, 27%), primarily due to reduced sudden death.
- While Group A had better pretransplant outcomes, posttransplant survival was similar to Group B and lower than event-free survival in Group A.
- Heart transplantation was performed more frequently in patients receiving intravenous support (Group C) compared to ACE-I alone (Group B).
Conclusions:
- Adding beta-blockers to ACE-I therapy is beneficial for patients with advanced heart failure referred for heart transplantation.
- For patients tolerating combined ACE-I and beta-blocker therapy, heart transplantation may not provide significant additional survival benefit in the short term.
- Optimal medical management, including beta-blockers, can improve outcomes and potentially alter the need for transplantation.
Background:
The aim of this study was to review our experience with beta-blocker therapy on top of high-dose angiotensin-converting enzyme inhibitors (ACE-I) in patients with advanced heart failure evaluated for heart transplantation, and to question the value of intended heart transplantation for patients receiving this therapy.
Methods:
Three hundred eighteen patients (New York Heart Association (NYHA) function class III 34%, class IV 66%, average left ventricular ejection fraction (LVEF) 16%, and average cardiac index 2.2 l/min per m(2) at time of referral) were treated with digitalis, loop diuretics, maximally uptitrated ACE-I, beta-blockers (if tolerated), and intravenous support (if needed). After 3 months, patients were retrospectively stratified into those receiving beta-blockers plus ACE-I (Group A, n = 126), ACE-I (Group B, n = 135), and ACE-I plus intravenous support (Group C, n = 57). Endpoint 1 of the study was combined urgent heart transplantation, mechanical assist device implantation, and pretransplant death during a follow-up of 12 to 48 (mean 19 +/- 11) months. Endpoint 2 was posttransplant mortality up to 48 (mean 14 +/- 8) months.
Results:
In the pretransplantation period the survival rate was 58% and the mortality rate was 20%. Between Groups A and B there was a significant difference in mortality (9% vs 27%, p = 0.001) due to a lower sudden-death rate in Group A (6% vs 17%, p < 0.01). While between Groups A and C all event rates of Endpoint 1 differed significantly, between Group C and Group B total mortality (30% vs 27%) was similar. However, in Group C urgent heart transplantation (HTx) was more often performed than in Group B (54% vs 11%, p < 0.0001). Seventy of 318 patients (22%) underwent heart transplantation (16% urgent, 6% elective). Posttransplant actuarial survival of the entire transplanted cohort (n = 70, 12 deaths) was significantly lower (log rank p < 0.01) than event-free survival in Group A (n = 126, 18 events), significantly higher (log rank p < 0. 0001) than event-free survival in Group C (n = 57, 34 events), and similar to that in Group B (n = 135, 52 events).
Conclusion:
This experience suggests that it may be particularly useful to add a beta-blocker to ACE-I therapy in patients referred for heart transplantation. In patients who tolerate this treatment, heart transplantation does not seem to provide additional survival benefit in the short term (2 years).