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Beta-blocker dosing in community-based treatment of heart failure
Michael B Fowler1, Sandra R Lottes, Jeanenne J Nelson
1Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, CA, USA.
Insights
Beta-blocker doses for heart failure (HF) patients in the community are often lower than in clinical trials, particularly when prescribed by non-cardiologists. Higher carvedilol doses are linked to reduced HF hospitalizations and death.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Community heart failure (HF) patients differ from trial participants: older, more comorbidities, less specialist care.
- These disparities may influence beta-blocker prescribing patterns in HF management.
- Understanding real-world prescribing is crucial for optimizing HF treatment.
Purpose of the Study:
- To examine beta-blocker (carvedilol) dosing in community-based HF patients.
- To identify factors associated with carvedilol dosage.
- To evaluate the relationship between carvedilol dose and HF hospitalization or death.
Main Methods:
- Analysis of 4113 patients from a community HF registry.
- Determined carvedilol doses at end titration.
- Correlated doses with physician and patient characteristics, HF severity, and clinical outcomes.
Main Results:
- Lower carvedilol doses were associated with female sex, age ≥65, LVEF ≥35%, and worse NYHA class.
- Cardiologists prescribed higher target doses (≥25 mg BID) more often than non-cardiologists.
- Higher carvedilol doses significantly reduced the risk of HF hospitalization and all-cause death.
Conclusions:
- Community HF beta-blocker dosing is generally lower than in clinical trials, especially by non-cardiologists.
- Carvedilol use, at any dose, reduced death and HF hospitalization compared to discontinuation.
- Optimizing beta-blocker therapy in community HF is essential for improving patient outcomes.
Background:
Community patients with heart failure (HF) are older, less often treated by HF specialists, and have more comorbidity than those in randomized clinical trials. These differences might affect beta-blocker prescribing in HF.
Methods:
To explore patterns of beta-blocker prescribing for HF in the community and their association with outcomes, we determined carvedilol doses at end titration in 4113 patients from a community-based beta-blocker HF registry according to physician and patient characteristics, HF severity, and rates of hospitalization and death.
Results:
Female sex, age > or = 65 years, and left ventricular ejection fraction > or = 35% were associated with lower beta-blocker doses. Average daily dose of beta-blocker was lower with worse baseline New York Heart Association class. More patients of cardiologists achieved carvedilol doses > or = 25 mg twice daily, whereas in those of noncardiologists lower doses were more common. Relative risk of HF hospitalizations or all-cause death was significantly lower with higher doses of beta-blocker.
Conclusions:
Beta-blocker dosing in community HF appears lower than in randomized clinical trials, especially when prescribed by noncardiologists. At all doses, patients taking the beta-blocker carvedilol have a lower incidence of death and HF hospitalization than those discontinuing it, regardless of physician type in the community setting.
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