title: Inpatient initiation of beta-blockade plus nurse management in vulnerable heart failure patients: a randomized study.
abstract: BACKGROUND
  Predischarge beta-blocker initiation in hospitalized patients with heart failure due to reduced left ventricular ejection fraction (LVEF) is safe and improves adherence; improved outcomes with this approach have not been demonstrated in a randomized trial. This study compared 6-month rehospitalization rates among patients assigned to predischarge beta-blockade coupled with postdischarge nurse management (intervention) versus usual care.
  
  
  RESULTS
  We randomized 64 patients with an LVEF </=0.40 to low-dose carvedilol coupled with nurse management or usual care. The nurse manager saw patients within 2 weeks of discharge, then biweekly until stable. Baseline characteristics reflected a vulnerable population (80% uninsured, 72% minorities, 80% unemployed or disabled), as did heart failure etiology (28% substance abuse, 27% ischemic, 19% hypertension, 17% idiopathic). Mean baseline LVEF was 0.23 in both groups. Among intervention patients at 6 -months, beta-blocker utilization was higher (96 vs. 48%, P < .001), mean New York Heart Association class improved (-1.44 vs. -0.77, P = .01), and total heart failure rehospitalizations were reduced by 84% (3 vs. 19, P = .02). A trend toward improved LVEF was also observed (+16 vs. +11 units, P = .17).
  
  
  CONCLUSIONS
  Inpatient beta-blocker initiation coupled with nurse management improved outcomes among sociodemographically disadvantaged heart failure patients. Our results support a practice shift toward inpatient beta-blocker initiation with structured outpatient follow-up.
authors.affiliation: Department of Medicine, Cardiology Division at Denver Health Medical Center and the University of Colorado Health Sciences Center; Colorado Prevention Center, Denver, Colorado, USA.
authors.forename: Mori J
authors.initials: MJ
authors.lastname: Krantz
authors.forename: Edward P
authors.initials: EP
authors.lastname: Havranek
authors.forename: Deborah K
authors.initials: DK
authors.lastname: Haynes
authors.forename: Inez
authors.initials: I
authors.lastname: Smith
authors.forename: Becki
authors.initials: B
authors.lastname: Bucher-Bartelson
authors.forename: Carlin S
authors.initials: CS
authors.lastname: Long
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D002227:Carbazoles / Q000627:therapeutic use*; D000077261:Carvedilol; D003120:Colorado; D019468:Disease Management; D005260:Female; D006305:Health Status Indicators; D006333:Heart Failure / Q000188:drug therapy* / Q000451:nursing* / Q000503:physiopathology; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D010359:Patient Readmission / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011412:Propanolamines / Q000627:therapeutic use*; D013318:Stroke Volume; D013997:Time Factors
chemical_list: D000319:Adrenergic beta-Antagonists; D002227:Carbazoles; D011412:Propanolamines; D000077261:Carvedilol