Patterns of beta-blocker intensification in ambulatory heart failure patients and short-term association with hospitalization.
BACKGROUND
In response to the short-term negative inotropic and chronotropic effects of β-blockers, heart failure (HF) guidelines recommend initiating β-blockers at low dose with gradual uptitration as tolerated to doses used in clinical trials. However, patterns and safety of β-blocker intensification in routine practice are poorly described.


METHODS
We described β-blocker intensification among Kaiser Colorado enrollees with a primary discharge diagnosis of HF between 2001-2009. We then assessed β-blocker intensification in the 30 days prior to first hospital readmission for cases compared to the same time period following index hospitalization for non-rehospitalized matched controls. In separate analysis of the subgroup initiated on β-blocker after index hospital discharge, we compared adjusted rates of 30-day hospitalization following initiation of high versus low dose β-blocker.


RESULTS
Among 3,227 patients, median age was 76 years and 37% had ejection fraction ≤ 40% (LVSD). During a median follow up of 669 days, 14% were never on β-blocker, 21% were initiated on β-blocker, 43% were discharged on β-blocker but never uptitrated, and 22% had discharge β-blocker uptitrated; 63% were readmitted and 49% died. β-blocker intensification occurred in the 30 days preceding readmission for 39 of 1,674 (2.3%) readmitted cases compared to 27 (1.6%) of matched controls (adjusted OR 1.36, 95% CI 0.81-2.27). Among patients initiated on therapy, readmission over the subsequent 30 days occurred in 6 of 155 (3.9%) prescribed high dose and 9 of 513 (1.8%) prescribed low dose β-blocker (adjusted OR 3.10, 95% CI 1.02-9.40). For the subgroup with LVSD, findings were not significantly different.


CONCLUSIONS
While β-blockers were intensified in nearly half of patients following hospital discharge and high starting dose was associated with increased readmission risk, the prevailing finding was that readmission events were rarely preceded by β-blocker intensification. These data suggest that β-blocker intensification is not a major precipitant of hospitalization, provided recommended dosing is followed.
Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. Larry.Allen@ucdenver.edu
Larry A
LA
Allen
David J
DJ
Magid
Chan
C
Zeng
Pamela N
PN
Peterson
Christina L
CL
Clarke
Susan
S
Shetterly
David W
DW
Brand
Frederick A
FA
Masoudi
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000639:trends*; D003120:Colorado; D004363:Drug Utilization; D017723:Drug Utilization Review; D005260:Female; D006279:Health Maintenance Organizations / Q000639:trends; D006333:Heart Failure / Q000188:drug therapy* / Q000503:physiopathology; D006760:Hospitalization / Q000639:trends*; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D010351:Patient Discharge / Q000639:trends; D010359:Patient Readmission / Q000639:trends; D061214:Patient Safety; D010818:Practice Patterns, Physicians' / Q000639:trends*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors
D000319:Adrenergic beta-Antagonists