Abstract
Introduction
Optimal pharmacologic therapy (OPT) is considered a prerequisite to consideration for cardiac resynchronization therapy (CRT).
Hypothesis
Medications such as beta‐blockers (BB) with demonstrated benefit in heart failure (HF) are being under utilized in patients receiving CRT.
Methods
Consecutive patients receiving a CRT‐capable defibrillator in 2004 at a tertiary care center for standard indications were studied. Clinical data and medications upon hospital discharge were recorded. Patients were followed for endpoints of death or transplantation.
Results
Of 177 patients receiving a CRT device, 129 (73%) received BB therapy (group 1). Of the 48 patients not on BBs (group 2), relative contraindications were documented in 21 (allergy in 3, hypotension or inotrope‐dependent HF in 4, chronic obstructive pulmonary disease [COPD] in 6, and amiodarone therapy in 8). The remaining 27 patients (group 3) did not receive BB therapy despite absence of documented justification. Compared to group 1, group 3 patients were similar in terms of clinical characteristics and angiotensin‐converting enzyme inhibitor (ACEI) use, but were less likely to be on statin therapy. Patients were followed for a mean of 19.9 ± 9.2 mo. After adjusting for age, QRS duration, creatinine, left ventricular ejection fraction (LVEF), statin use, and presence of ischemic HF etiology, patients not receiving BB therapy in the absence of contraindication had increased risk of death or transplantation (odds ratio [OR]: 3.1, p = 0.043).
Conclusions
Absence of BB therapy appears to be independently associated with poor outcome in CRT recipients. These results suggest that a crucial component of OPT may be underutilized in a population of HF patients receiving CRT. Copyright © 2009 Wiley Periodicals, Inc.
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References
- 1. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, et al.: Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346: 1845–1853. [DOI] [PubMed] [Google Scholar]
- 2. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, et al.: Cardiac‐resynchronization therapy with or without an implantable cardioverter‐defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–2150. [DOI] [PubMed] [Google Scholar]
- 3. Cleland JGF, Daubert J, Erdmann E, Freemantle N, Gras D, et al.: The effect of cardiac resynchronization of morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539–1549. [DOI] [PubMed] [Google Scholar]
- 4. Hunt SA, Abraham WT, Chin M, Feldman AM, Francis GS, et al.: 2005 ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult. J Am Coll Cardiol 2005; 46: 1116–1143. [DOI] [PubMed] [Google Scholar]
- 5. Packer M, Bristow MR, Cohn JN, Colucci WSM, Fowler MB, et al.: The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996; 334: 1349–1355. [DOI] [PubMed] [Google Scholar]
- 6.CIBIS II Investigators and Committees: The cardiac insuffiency bisoprolol study II (CIBIS II): A randomized trial. Lancet 1999; 353: 9–13. [PubMed] [Google Scholar]
- 7.MERIT‐HF Study Group: Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT‐HF). Lancet 1999; 353: 2001–2007. [PubMed] [Google Scholar]
- 8. Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC, et al.: The EuroHeart Failure Survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 2: Treatment. Eur Heart J 2003; 24: 464–474. [DOI] [PubMed] [Google Scholar]
- 9. Cleland JG, Cohen‐Solal A, Aguilar JC, Dietz R, Eastaugh J, et al.: Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): An international survey. Lancet 2002; 360: 1631–1639. [DOI] [PubMed] [Google Scholar]
- 10. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, et al.: Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA 2007; 297: 61–70. [DOI] [PubMed] [Google Scholar]
- 11. Packer M, Coats AJS, Fowler MB, Kahs HA, Krum H, et al.: Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med 2001; 344: 1651–1658. [DOI] [PubMed] [Google Scholar]
- 12. Takemoto Y, Hozumi T, Sugioka K, Takagi Y, Matsumura Y, et al.: Beta‐blocker therapy induces ventricular resynchronization in dilated cardiomyopathy with narrow QRS complex. J Am Coll Cardiol 2007; 49: 778–783. [DOI] [PubMed] [Google Scholar]
- 13. Patel P, White DL, Deswal A: Translation of clinical trial results into practice: Temporal patterns of B‐blocker utilization for heart failure at hospital discharge and during ambulatory follow‐up. Am Heart J 2007; 153: 515–522. [DOI] [PubMed] [Google Scholar]
- 14. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, et al.: Carvedilol use at discharge in patients hospitalized for heart failure is associated with improved survival: An analysis from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE‐HF). Am Heart J 2007; 153: 82.e1–82.e11. [DOI] [PubMed] [Google Scholar]
- 15. Achilli A, Peraldo C, Sassara M, Orazi S, Bianchi S, et al.: Prediction of response to cardiac resynchronization therapy: The selection of candidates for CRT (SCART study). Pacing Clin Electrophysiol 2006; 29: S11–9. [DOI] [PubMed] [Google Scholar]
- 16. De Sisti A, Toussaint JF, Lavergne T, Ollitrault J, Abergel E, et al.: Determinants of mortality in patients undergoing cardiac resynchronization therapy: Baseline clinical, echocardiographic, and angioscintigraphic evaluation prior to resynchronization. Pacing Clin Electrophysiol 2005; 28: 1260–1270. [DOI] [PubMed] [Google Scholar]
- 17. Bax JJ, Bleeker GB, Marwick TH, Molhoek SG, Boersma E, et al.: Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol 2004; 44: 1834–1840. [DOI] [PubMed] [Google Scholar]
- 18. Yamada T, Node K, Mine T, Merita T, Kioka H, et al.: Long‐term effect of atorvastatin on neurohumoral activation and cardiac function in patients with chronic heart failure: A prospective randomized controlled study. Am Heart J 2007; 153(6): 1055.e1–8. [DOI] [PubMed] [Google Scholar]
- 19. Sola S, Mir MQ, Lerakis S, Tandon N, Khan BV, et al.: Atorvastatin improves left ventricular systolic function and serum markers of inflammation in noninschemic heart failure. J Am Coll Cardiol 2006; 47(2): 332–337. [DOI] [PubMed] [Google Scholar]