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. METHODS AND RESULTS: We randomized 64 patients with an LVEF </=0.40 to low-dosecarvedilol 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). CONCLUSION: 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.
RCT Entities:
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. METHODS AND 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). CONCLUSION: Inpatient beta-blocker initiation coupled with nurse management improved outcomes among sociodemographically disadvantaged heart failurepatients. Our results support a practice shift toward inpatient beta-blocker initiation with structured outpatient follow-up.
Authors: Sarah L Cutrona; Niteesh K Choudhry; Michael A Fischer; Amber Servi; Joshua N Liberman; Troyen A Brennan; William H Shrank Journal: Am J Manag Care Date: 2010 Impact factor: 2.229
Authors: Robby Nieuwlaat; Nancy Wilczynski; Tamara Navarro; Nicholas Hobson; Rebecca Jeffery; Arun Keepanasseril; Thomas Agoritsas; Niraj Mistry; Alfonso Iorio; Susan Jack; Bhairavi Sivaramalingam; Emma Iserman; Reem A Mustafa; Dawn Jedraszewski; Chris Cotoi; R Brian Haynes Journal: Cochrane Database Syst Rev Date: 2014-11-20