Timing of cardiac transplantation in patients with heart failure receiving beta-adrenergic blockers.
BACKGROUND
Previous work shows that patients with heart failure patients who have peak oxygen consumption (VO2 peak) >14 ml/kg/min do not derive a survival benefit from cardiac transplantation. However, this was shown before beta-blocker therapy for patients with systolic heart failure became common, and beta-blockers improve survival in patients with heart failure without changing VO(2) peak. Our purpose was to re-evaluate the utility of VO(2) peak >14 ml/kg/min as an indicator of the need for cardiac transplantation in patients with heart failure who are taking beta-blockers.


METHODS
Actuarial, hemodynamic, and exercise ventilatory data were collected from 540 patients with heart failure, 256 of whom were taking beta-blockers. We tracked death and cardiac transplantation. We stratified the percentage of patients event-free 1 and 3 years after VO(2) peak study by their VO(2) peak and beta-blocker status, and compared 1- and 3-year post-transplant survival (United Network of Organ Sharing [UNOS] data). We also compared total mortality for the patients with heart failure as stratified by beta-blocker stats and VO(2) peak (excluding the 42 who underwent transplantation) with UNOS post-transplant survival.


RESULTS
Patients with heart failure who were receiving beta-blockers and whose VO(2) peak was > or =12 ml/kg/min had greater 1- and 3-year event-free survival rates (95% confidence intervals, 92.6%-96.6% and 85.8%-96.0%) than did post-transplant patients (83.9%-86.3% and 75.4%-76.6%). However, in patients with heart failure not taking beta-blockers, VO(2) peak <14 ml/kg/min was associated with worse 3-year survival (38.9 - 62.1%) than that for post-transplant patients. Excluding the 42 patients with heart failure in our study who underwent transplantation and then evaluating survival of the remaining patients with heart failure (not event-free survival) did not substantially change these results.


CONCLUSIONS
Patients with heart failure who are receiving beta-blockers do not derive a survival advantage at 1 and 3 years after cardiac transplantation if VO(2) peak is > or =12 ml/kg/min. Patients not taking beta-blockers whose VO(2) peak is <14 ml/kg/min have superior survival with cardiac transplantation.
Peterson
Linda R
LR
Cardiovascular Division, Washington University School of Medicine, Campus Box 8086, 660 S. Euclid Avenue, St. Louis, MO 63110, USA. lpeterso@im.wustl.edu
Schechtman
Kenneth B
KB
Ewald
Gregory A
GA
Geltman
Edward M
EM
de las Fuentes
Lisa
L
Meyer
Timothy
T
Krekeler
Pamela
P
Moore
Martha L
ML
Rogers
Joseph G
JG
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D016022:Case-Control Studies; D016208:Databases, Factual / Q000706:statistics & numerical data; D018572:Disease-Free Survival; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010101:Oxygen Consumption / Q000502:physiology; D011379:Prognosis; D018570:Risk Assessment; D015996:Survival Rate; D013997:Time Factors
D000319:Adrenergic beta-Antagonists