Clinical InvestigationsTolerability to β-blocker therapy among heart failure patients in clinical practice*,**
Section snippets
Patient population
A total of 360 consecutive patients treated at either the Vanderbilt University Medical Center or the Nashville Veterans Administration Medical Center's HF Programs between January 1999 and June 2000 who either died or had a documented follow-up visit at least 1 month after initiation of β-blocker therapy were identified. To study typical HF patients with systolic dysfunction, we excluded 43 patients with an ejection fraction >40%; 18 patients with any of the following: aortic stenosis,
Outcomes
The primary outcome was the proportion of patients with an absolute intolerance to β-blockers. Other outcomes included assessment of side effects profile, frequency of patients who were successfully switched to another β-blocker if one was not tolerated, and predictors of discontinuation of β-blockers.
Results
The mean age of the study population was 59 ± 11 years and 71% of the patients were males. Mean ejection fraction was 24 ± 8%. Other demographic, clinical characteristics, histories, and baseline HF treatments are presented in Table 1.Characteristics Overall Tolerated n = 217 Discontinued n = 51 P Age (mean ± SD) 59 ± 11 59 ± 12 58 ± 10 NS Male gender (%) 71 72 68 NS NYHA class (%) I-II 37 41 20 .01 III-IV 63 59 80 Etiology (%) Ischemic 55 59 39 .02 Nonischemic 45 41 61 Ejection fraction (mean ± SD) 24 ± 8
Discussion
Several clinical trials have now shown that β-blockers reduce mortality and hospitalization rate and improve left ventricular ejection fraction among HF patients, and that these drugs were well-tolerated in clinical trials.1, 2, 3, 4 Previous studies have, however, shown a difference in drug tolerability between patients in clinical trials vs. practice setting.7 In the case of β-blockers, this disparity may be important as untreated worsening congestion can be life-threatening. On the other
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Cited by (36)
Achieving a Maximally Tolerated β-Blocker Dose in Heart Failure Patients: Is There Room for Improvement?
2017, Journal of the American College of CardiologyCitation Excerpt :HF patients with comorbid peripheral vascular disease or Raynaud disease may benefit from carvedilol, given its positive effects on vascular tone. In cases of intolerance refractory to dose reduction, efforts should be made to switch to another evidence-based β-blocker, given the discussed improvement in adherence rates with in-class switching (35). Other crossover studies, including a secondary analysis from COMET (Carvedilol or Metoprolol European Trial), showed similar findings.
Benefits of Heart Rate Slowing With Ivabradine in Patients With Systolic Heart Failure and Coronary Artery Disease
2016, American Journal of CardiologyThe calcium channel blocker felodipine attenuates the positive hemodynamic effects of the β-blocker metoprolol in severe dilated cardiomyopathy - A prospective, randomized, double-blind and placebo-controlled study with invasive hemodynamic assessment
2009, International Journal of CardiologyCitation Excerpt :Despite the negative inotropic effects of metoprolol and felodipine, all “MF and MP” patients tolerated the initiation phase of double-blind therapy, providing evidence for the safety of slowly titrating both drugs during the early phase of drug administration [6,18,19]. The low incidence of patients with progression of heart failure in our study might result from the fact, that all included CHF patients had a dilative cardiomyopathy being stable in functional NYHA class II–III, which is rather lower than compared to more critically ill and symptomatic CHF patients in other trials [20–23]. The results of the present study clearly demonstrate a favorable effect of metoprolol on left ventricular function (improvement of EF, reduction in LVEDD) and hemodynamic parameters as compared to placebo, which is in good agreement with other trials reporting a beneficial effect of different β1-selective-blockers (metoprolol, bisoprolol) and carvedilol on clinical symptoms, rate of hospitalization as well as overall mortality during long-term follow-up [1–4].
Impact of Optimal Heart Failure Medical Therapy on Heart Transplant Listing
2006, Transplantation ProceedingsOutpatient intravenous diuretic therapy; potential for marked reduction in hospitalisations for acute decompensated heart failure
2008, European Journal of Heart Failure
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Reprint requests: Javed Butler MD, Cardiology Division, 383 PRB, Vanderbilt University Medical Center, Nashville, TN 37232.
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