Clinical Outcomes in Patients on Beta‐Blocker Therapy Admitted With Worsening Chronic Heart Failure

Beta blockers have been shown to reduce morbidity and mortality in patients with heart failure without evidence of overt congestion.No data are available describing outcomes of patients admitted with exacerbated chronic heart failure who are receiving β blockade at the time of admission.The purpose of this analysis was to evaluate clinical outcomes in patients from the Outcomes of the Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study who were prescribed β blockers on admission compared with patients who were not prescribed β blockers at admission.In all, 212 patients were treated with β blockers at admission and 737 patients were not.Baseline characteristics were similar between groups, except that patients prescribed β blockers on admission had slightly higher ejection fractions, fewer New York Heart Association class IV symptoms, and lower heart rates.There was no difference in clinical events between patients who were treated with β blockers at the time of admission and those who were not.Exploratory analyses suggested that patients whose β blocker therapy was discontinued had a higher risk of adverse outcomes, particularly in the subset of patients randomized to milrinone.The data from this nonrandom comparison suggest that continuation of preexisting β blocker therapy is not associated with an increased risk of adverse clinical events in patients admitted with worsening heart failure.These results also suggest that caution should be taken when withdrawing β blockade in this population.-GattisWA, O'Connor CM, Leimberger JD, et al.Clinical outcomes in patients on beta-blocker therapy admitted with worsening chronic heart failure.Am J Cardiol.2003; 91(2):169-174.Comment.Over the last 10 years or so, there has been a major advance in our understanding of the pathophysiology of heart failure, as well as new therapies directed at this mechanism.Specifically, I am referring to the addition of β blocker therapy for patients with symptomatic heart failure due to systolic dysfunction.As the cardiovascular community has expanded its utilization of this class of drugs, we have also gained an increased respect for the potential side effects when these agents are introduced.Among the most common adverse effects that arise during the titration phase is decompensated heart failure.With this in mind, many clinicians, myself included, have been forced to cut back on dosages of the medicine and/or increase diuretic use during initial phases.However, a clinical question that has arisen, and which has not been thoroughly elucidated in the literature, is what to do when a patient with heart failure arrives in the emergency room in a decompensated state and has already been on long-term β blocker therapy.What all good clinicians know is that you should try to integrate some common-sense clinical experience and scientific data into the equation when deciding how to proceed.Unfortunately, since the use of β blockers in heart failure is relatively new, there exists a paucity of information on how to proceed in the setting of people who have already been taking β blockers for quite some time and then developed symptomatic systolic dysfunction.With this in mind, Gattis et al. looked at data from the OPTIME-CHF study.This was a multicenter, randomized, double-blind controlled trial, using the inotropic agent milrinone vs. placebo in patients who needed hospitalization for decompensated chronic heart failure.Analyzing the data, they sought to determine whether those patients who had arrived already on chronic β blocker therapy would have worse outcomes than those not treated with β blockers at the time of hospital admission.As a secondary end point, they sought to determine the clinical outcomes for patients who Frontiers in Congestive Heart Failure