Suboptimal Dosing of β-Blockers in Chronic Heart Failure: A Missed Opportunity?
Melanie McGinlay, Sam Straw, Rowenna Byrom-Goulthorp and 5 others
PMID 34321430WHAT IT FOUND
One year after heart failure clinic enrolment, 61% of 390 patients had β-blocker doses at or above 5-mg bisoprolol equivalent.
Those below that dose were observed to have worse survival, whether or not blood pressure and heart rate allowed up-titration.
Key findings
01In the final cohort of 390 patients, 237 (61%) were receiving optimized β-blocker dosing at 1 year, 72 (18%) could not be up-titrated, and 81 (21%) should have been up-titrated but were not.
02Bisoprolol equivalent dose at follow-up was associated with a reduction in mortality in adjusted analyses, with reported values of 0.95 (95% confidence interval, 0.91–0.98; P = .004) and 0.96 (95% confidence interval, 0.92–1.00; P = .029).
03Survival was lower in patients receiving suboptimal β-blocker doses, regardless of whether they could not be up-titrated or should have been up-titrated.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
This was an observational cohort, not a randomised trial, so it cannot show that raising β-blocker dose caused better survival. Patients also received other heart failure therapies, including ACE inhibitors, loop diuretics, and device therapy, so the effect of β-blocker dose alone cannot be separated. The final analysis included 390 patients, not all 628 recruited; 408 attended the 1-year visit and 18 had missing data. Only heart rate and blood pressure were used to classify who could or should have been up-titrated, and the authors could not explain most failures to optimize dose. Findings do not apply to heart failure with preserved ejection fraction because patients with left ventricular ejection fraction greater than 45% were excluded. Socioeconomic status was not explored.
Declared interests
One author received speakers' fees and honoraria from Medtronic, Cardiac Dimensions, Novartis, Abbott, BMS, Pfizer, and Bayer, plus an unconditional research grant from Medtronic. The other authors reported no conflicts of interest.
The easy way to misread this
Do not conclude that increasing β-blocker dose will improve survival. This was an observational cohort, not a trial of dose escalation, and patients also received other heart failure treatments. Some patients could not be up-titrated because of low heart rate or blood pressure.