Prescription Of Beta-blockers Research Articles

Trends of Antihypertensive Prescription Among US Adults From 2010 to 2019 and Changes Following Treatment Guidelines: Analysis of Multicenter Electronic Health Records.

Guidelines for the use of antihypertensives changed in 2014 and 2017. To understand the effect of these guidelines, we examined trends in antihypertensive prescriptions in the United States from 2010 to 2019 using a repeated cross-sectional design. Using electronic health records from 15 health care institutions for adults (20-85 years old) who had ≥1 antihypertensive prescription, we assessed whether (1) prescriptions of beta blockers decreased after the 2014 Eighth Joint National Committee (JNC 8) report discouraged use for first-line treatment, (2) prescriptions for calcium channel blockers and thiazide diuretics increased among Black patients after the JNC 8 report encouraged use as first-line therapy, and (3) prescriptions for dual therapy and fixed-dose combination among patients with blood pressure ≥140/90 mm Hg increased after recommendations in the 2017Hypertension Clinical Practice Guidelines. The study included 1 074 314 patients with 2 133 158 prescription episodes. After publication of the JNC 8 report, prescriptions for beta blockers decreased (3% lower in 2018-2019 compared to 2010-2014), and calcium channel blockers increased among Black patients (20% higher in 2015-2017 and 41% higher in 2018-2019, compared to 2010-2014), in accordance with guideline recommendations. However, contrary to guidelines, dual therapy and fixed-dose combination decreased after publication of the 2017 Hypertension Clinical Practice Guidelines(9% and 11% decrease in 2018-2019 for dual therapy and fixed-dose combination, respectively, compared to 2015-2017), and thiazide diuretics decreased among Black patients after the JNC8 report (6% lower in 2018-2019 compared to 2010-2014). Adherence to guidelines on prescribing antihypertensive medication was inconsistent, presenting an opportunity for interventions to achieve better blood pressure control in the US population.

Do beta-blockers reduce negative intrusive thoughts and anxiety in cancer survivors? – An emulated trial

BackgroundHigh rates of negative intrusive thoughts have been reported among cancer patients. Prevalent users of beta-blocker therapy have reported lower levels of cancer related intrusive thoughts than non-user. The aim of this study is to investigate if initiation of beta-blocker therapy reduces the prevalence and severity of intrusive thoughts (co-primary endpoints) and the prevalence of anxiety, depressed mood, and low quality of life (secondary endpoints) in cancer survivors.MethodsData on patient-reported outcomes from three cohort studies of Swedish patients diagnosed with colon, prostate or rectal cancer were combined with data on beta-blocker prescriptions retrieved from the Swedish Prescribed Drug Register. Two randomized controlled trials were emulated. Trial 1 had follow-up 1 year after diagnosis, trial 2 had follow-up 2 years after diagnosis, baseline in both trials was 12 months before follow-up. Those who initiated beta-blocker therapy between baseline and follow-up was assigned Active group, those who did not was assigned Control group. All endpoints were analysed using Bayesian ordered logistic regression.ResultsTrial 1 consisted of Active group, n = 59, and Control group, n = 3936. Trial 2 consisted of Active group, n = 87, and Control group, n = 3132. The majority of participants were men, 83% in trial 1 and 94% in trial 2. The prevalence and severity of intrusive thoughts were lower in the Active group in trial 1, but no significant differences between groups were found in either trial. The prevalence of depressed mood, worse quality of life and periods of anxiety were higher in the Active group in both trials with significant differences for quality of life in trial 1 and anxiety in trial 2.ConclusionsThe emulated trials demonstrated no evidence of a protective effect of beta-blocker therapy against intrusive thoughts. The Active group had reduced quality of life and elevated anxiety compared to the Control group.Trial registrationThe three cohort studies were registered at isrctn.com/clinicaltrials.gov (ISRCTN06393679, NCT02530593 and NCT01477229).

European Association of Cardiovascular Imaging (EACVI) survey on Cardiovascular Multimodality Imaging in Acute Myocarditis.

To assess the current role of cardiac imaging in the diagnosis, management, and follow-up of patients with acute myocarditis (AM) through an European Association of Cardiovascular Imaging survey. A total of 412 volunteers from 74 countries responded to the survey. Most participants worked in tertiary centres(56%). All participants had access to echocardiography, while 79% and 75% had access to cardiac computed tomography (CCTA) and cardiac magnetic resonance (CMR), respectively. Less than half(47%) had access to myocardial biopsy and only 5% used this test routinely. CMR was performed within 7 days of presentation in 73% of cases. Non-ischemic late gadolinium enhancement (LGE,88%) and high-signal intensity in T2-weighted images(74%) were the most used diagnostic criteria for AM. CCTA was preferred to coronary angiography by 47% of participants to exclude coronary artery disease. Systematic prescription of beta-blockers and ACEi was reported by 38% and 32% of participants. Around a quarter of participants declared considering LGE burden as a reason to treat. Most participants (90%) reported performing a follow-up echocardiogram, while 63% scheduled a follow-up CMR. The main reason for treatment discontinuation was improvement of left ventricular ejection fraction(89%), followed by LGE regression(60%). In two-thirds of participants the decision to resume high-intensity sport was influenced by residual LGE. This survey confirms the high utilization of cardiac imaging in AM, but reveals major differences in how cardiac imaging is used and how the condition is managed between centres, underlining the need for recommendation statements in this topic.

Beta Blockers in Contemporary Cardiology: Is It Better to Cast Them Out?

Beta blockers are one of the commonest prescription drugs in medicine and they have been thought to revolutionize the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) in the last century. In addition to HFrEF, they are prescribed for a variety of diseases in cardiology from hypertension to HF, angina, and stable coronary artery disease (CAD). The increased prescription of beta blockers in conditions like HF with preserved ejection fraction (HFpEF), and stable CAD may be doing more harm than good as per the data we have so far. The available data shows that beta blockers are associated with increased stroke risk and atrial fibrillation (AF) in hypertension and in patients with HFpEF, they have been associated with decreased exercise capacity. In patients with stable CAD and patients with myocardial infarction with normal systolic functions, beta blockers don't offer any mortality benefit. In this article, we critically review the common indications and the uses of beta blockers in patients with HFpEF, CAD, hypertension and AF and we propose that beta blockers are over-prescribed under the shadow of their beneficial effects in patients with HFrEF.

Management and outcome in foreign-born vs native-born patients with myocardial infarction in Sweden.

Previous studies on disparities in healthcare and outcome have shown conflicting results. The aim of this study was to assess differences in baseline characteristics, management, and outcome in myocardial infarction (MI) patients, by country of birth. In total, 194 259 MI patients (64% male, 15% foreign-born) from the nationwide SWEDEHEART registry were included and compared by geographic region of birth. The primary outcome was one-year major adverse cardiovascular events (MACE) including all-cause death, MI, and stroke. Secondary outcomes were long-term MACE (up to 12 years), the individual components of MACE, 30-day mortality, management, and risk factors. Logistic regression, Cox proportional hazard models and propensity score matching (PSM), accounting for baseline differences, were used. Foreign-born patients were younger, often male, and had a higher cardiovascular (CV) risk factor burden, including smoking, diabetes, and hypertension. In PSM analyses, Asia-born patients had higher likelihood of revascularisation (OR 1.16, 95% CI 1.04-1.30), statins and betablocker prescription at discharge and a 34% lower risk of 30-day mortality. Furthermore, no statistically significant differences were found in the primary outcomes except for Asia-born patients having lower risk of one-year MACE (HR 0.85, 95% CI 0.73-0.98), driven by lower mortality (HR 0.72, 95% CI 0.57-0.91). The results persisted over long-term follow-up. This study shows that in a system with universal healthcare coverage in which acute and secondary preventive treatments do not differ by country of birth, foreign-born patients, despite higher CV risk factor burden, will do at least as well as native-born patients.

Predicting factors for omitting beta-blockers in patients with tachycardia-induced cardiomyopathy after successful catheter ablation for atrial fibrillation.

Tachycardia induces a reduction in the left ventricular ejection fraction (LVEF), which is defined as tachycardia-induced cardiomyopathy (TIC). Conversion to and maintenance of sinus rhythm by catheter ablation can improve LVEF in patients with TIC due to atrial fibrillation (AF). Beta-blockers are mandatory for the treatment of heart failure with reduced LVEF(HFrEF), but the necessity of beta-blockers in TIC patients even after catheter ablation remains unclear. We examined the effect of beta-blockers on cardiac function in TIC patients after catheter ablation. We retrospectively analyzed 124 patients with a history of heart failure and an LVEF of ≤ 50% who underwent catheter ablation for AF. TIC was defined as a ≥ 10% improvement in the baseline LVEF and an improvement to an LVEF of ≥ 50% at 6months after ablation. Patients with other cardiomyopathy diagnosed before the ablation were excluded. LVEF was significantly increased with the reductions of the left ventricular and left atrial volumes at the 6-month follow-up in all 80 patients with TIC. No beta-blockers were prescribed during the post-ablation follow-up in 21 patients with TIC. The absolute values of and changes in the echocardiographic parameters between before and after ablation were not significantly different between patients with and without beta-blockers after the ablation. A simple score using the history of hospitalization for heart failure and use of beta-blockers or diuretics prior to ablation was useful in identifying TIC patients who did not need prescription of beta-blockers after catheter ablation. LVEF similarly improved in both patients with and without prescription of beta-blockers after the ablation. Beta-blockers may not need to be prescribed after successful catheter ablation for AF in LVEF of ≤ 50% patients without other cause of cardiomyopathy diagnosed before the ablation, a history of hospitalization for heart failure and prescription of beta-blockers and diuretics before the ablation.

Factors associated with longer survival among older medicare patients after diagnosis of supratentorial primary brain malignancies: a retrospective cohort study

ABSTRACT Objectives Despite recent advances, the prognosis for primary malignant brain tumors (PMBTs) remains poor. Some commonly prescribed medications may exhibit anti-tumor properties in various cancers, and neurodegenerative diseases may activate pathways that counteract gliomagenesis. Our study is focused on determining if there is a correlation between the use of metformin, beta-blockers, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs), or the presence of Parkinson’s disease (PD), and the survival rates following a diagnosis of a PMBT. Methods This analysis of the 100% Texas Medicare Database identified patients aged 66+ years diagnosed with a supratentorial PMBT from 2014–2017. Cox proportional hazards regression was employed to analyze survival following diagnosis and associations of survival with surgical intervention, radiation, PD diagnosis, and prescription of metformin, beta-blockers, ACEIs, or ARBs. Results There were 1,943 patients who met study criteria, and the median age was 74 years. When medication utilization was stratified by none, pre-diagnosis only, post-diagnosis only, or both pre- and post-diagnosis (continuous), continuous utilization of metformin, beta-blockers, ACEIs, or ARBs was associated with prolonged survival compared to no utilization (hazard ratio [HR]:0.45, 95% CI:0.33–0.62; HR:0.71. 95% CI:0.59–0.86; HR:0.59, 95% CI:0.48–0.72; and HR:0.45, 95% CI:0.35–0.58 respectively). PD was also associated with longer survival (HR:0.59–0.63 across the four models). Discussion Our study suggests that metformin, beta-blockers, ACEIs, ARBs, and comorbid PD are associated with a survival benefit among geriatric Medicare patients with supratentorial PMBTs.

Impacto pronóstico de la enfermedad pulmonar obstructiva crónica y el asma bronquial en pacientes con insuficiencia cardiaca

PurposeTo analyze the impact of chronic obstructive pulmonary disease (COPD) and bronchial asthma on therapeutic management and prognosis of patients with heart failure (HF). MethodsAnalysis of the information collected in a clinical registry of patients referred to a specialized HF unit from January-2010 to June-2012. Clinical profile, treatment and prognosis of patients was evaluated, according to the presence of COPD or asthma. Survival analyses were conducted by means of Kaplan-Meier and Cox's methods. Median follow-up was 1493 days. ResultsWe studied 2577 patients, of which 251 (9.7%) presented COPD and 96 (3.7%) bronchial asthma. Significant differences among study groups were observed regarding to the prescription of beta-blockers (COPD=89.6%; asthma=87.5%; no bronchopathy=94.1%; P=.002) and SGLT2 inhibitors (COPD=35.1%; asthma=50%; no bronchopathy=38.3%; P=.036). Also, patients with bronchial disease received less frequently a defibrillator (COPD=20.3%; asthma=20.8%; no broncopathy=29%; P=.004).COPD was independently associated with increased risk of all-cause mortality (HR=1.64; 95%CI: 1.33-2.02), all-cause death or HF admission (HR=1.47; 95%CI: 1.22-1.76) and cardiovascular death or heart transplantation (HR=1.39; 95%CI: 1.08-1.79) as compared with patients with no bronchopathy. Bronchial asthma was not significantly associated with increased risk of adverse outcomes. ConclusionsCOPD, but not asthma, is an adverse independent prognostic factor in patients with HF.

Catheter ablation for supraventricular tachycardia and health resource utilization and expenditures: A propensity-matched cohort study

BackgroundFew data are available regarding temporal patterns of health resource utilization (HRU) and expenditures among patients undergoing catheter ablation for paroxysmal supraventricular tachycardia (PSVT). This study aimed to describe expenditures and HRU in patients with PSVT who underwent catheter ablation compared to a matched cohort of patients on medical therapy alone. MethodsUsing a large US administrative database, we identified adult patients (age 18 to 65 years) with a new PSVT diagnosis between 2008 and 2016. Propensity-score matching was used to assemble a PSVT cohort treated with ablation or medical therapy alone (N = 2556). Longitudinal trends in HRU and expenditures in the 3-years preceding and following PSVT diagnosis were compared. ResultsThere were no significant differences in expenditures between groups except within the first year after PSVT diagnosis: $48,004 ablation vs. $17,560 medical therapy (p < 0.001). This difference was driven by procedural expenditures, where the mean cost of catheter ablation was $32,057 ± SD 26,737. In Years 2 and 3 post-ablation, HRU and expenditures decreased to the levels associated with the medical therapy group, although fewer ablation patients required any prescription for beta-blockers, calcium channel blockers, or anti-arrhythmic drugs (32% ablation vs. 42% medical therapy group, p < 0.001). ConclusionCatheter ablation reduces medication burden in PSVT, yet health resource use and expenditures were similar beyond 2 years post-ablation when compared to PSVT patients on medical therapy alone. Additional studies are required to better understand drivers of these sustained health expenditures, and barriers to achieving cost-savings for a potentially curative procedure.

Abstract TMP107: Persistent Beta-Blocker Use and Mortality Reduction in Acute Ischemic Stroke Patients

Background: The efficacy of beta-blockers in acute ischemic stroke remains ambiguous. Research targeting high-risk patients, especially those with elevated heart rates, is crucial. Methods: A comprehensive multicenter registry of acute ischemic stroke patients was integrated with the National Health Insurance Service database. We focused on patients exhibiting a heart rate of ≥100 bpm between days 3-7 post-symptom onset. These patients were categorized based on whether they received a beta-blocker prescription by day 8. To account for potential imbalances, we employed Cox’s proportional hazard model with inverse-probability of treatment weighting based on propensity score. The primary outcome was composite of stroke recurrence, myocardial infarction, and mortality within a year post-stroke. Recognizing the significant discontinuation rate of beta-blockers, we conducted an additional analysis on persistent users and landmark analysis at 2-month, 1-year, and 2-year intervals. Results: Out of 5,049 patients, 1,623 (32.1%) were prescribed with beta-blockers by the 8th day. Beta-blocker usage did not significantly influence the primary outcome within the first year (IPTW adjusted HR [95% CI], 0.98 [0.86-1.12]). However, patients who consistently used beta-blockers beyond 2 months exhibited a reduced mortality risk (adjusted HR, 0.88 [0.78-0.99]). Landmark analysis further revealed that consistent beta-blocker usage notably decreased mortality risk at 8-day to 2-month (IPTW adjusted HR [95% CI], 0.80 [0.69-0.93]) and 2-month to 1-year intervals (IPTW adjusted HR [95% CI], 0.80 [0.68-0.94]). Conclusion: Our findings suggest that beta-blockers can potentially reduce mortality in acute ischemic stroke patients, with consistent usage being a pivotal factor.

Central vs peripheral vascular factors determining risk of aortic dissection

Hypertension is the commonest cause of “central” aortic dissection, despite being an “peripheral” arteriole disease. We hypothesised that known regional variations in peripheral organ perfusion, due to variation in arteriole tone, via its effect on differential head and neck vessel flows can alter the risk and location of central aortic dissection. This might help to explain why some hypertensive patients dissect their aorta and others don't despite having similar aortic geometry. We utilised a simple 2D computational fluid dynamic model to test our hypothesis. We hypothesise (1) that variations in “peripheral” organ flow can alter the site of “central” aortic dissection, despite the blood pressure and cardiac output being identical, (2) variations in cardiac output at rest may also help to explain the risk of dissection but not the site of the initial intimal tear, and (3) atrial fibrillation, a known factor for aortic dissection, increases the risk via stroke volume variation. MRI scanning, via regional aortic branch flow quantification, may help to identify individuals who have a family history of dissection/aneurysm, who are normotensive with normal aortic anatomy that have a high potential risk for dissection due to calculated high wall velocity/shear stresses. This may allow selective beta blocker prescriptions in an asymptomatic patient population that is at a predicted high risk of aortic dissection – a hither to unidentified patient subpopulation.

Association between Incidence of Prescriptions for Alzheimer's Disease and Beta-Adrenoceptor Antagonists: A Prescription Sequence Symmetry Analysis.

Alzheimer's disease (AD) is the most common cause of dementia, with a growing number of patients worldwide. The association between AD and treatment with drugs targeting the beta-adrenergic receptor is controversial. The aim of this study is to assess the association between the initiation of AD medication and beta-adrenoceptor antagonists (beta-blockers) in adults. We conducted a prescription sequence symmetry analysis using the University of Groningen IADB.nl prescription database. We determined the order of the first prescription for treating AD and the first prescription for beta-blockers, with the dispensing date of the first prescription for AD defined as the index date. Participants were adults over 45 years old starting any AD medication and beta-blockers within two years. We calculated adjusted sequence ratios with corresponding 95% confidence intervals. We identified 510 users of both AD and beta-blockers, and 145 participants were eligible. The results were compatible with either a significant decrease in the incidence of AD after using beta-blockers (adjusted sequence ratio (aSR) = 0.52; 95% CI: 0.35-0.72) or, conversely, an increase in beta-blockers after AD medication (aSR = 1.96; 95% CI: 1.61-2.30). There is a relationship between the use of beta-blockers and AD medications. Further research is needed with larger populations to determine whether drug therapy for AD increases the risk of hypertension or whether beta-blockers have potential protective properties against AD development.

Cohort profile: a large EHR-based cohort with linked pharmacy refill and neighbourhood social determinants of health data to assess heart failure medication adherence

PurposeClinic-based or community-based interventions can improve adherence to guideline-directed medication therapies (GDMTs) among patients with heart failure (HF). However, opportunities for such interventions are frequently missed, as providers may be...

Quadruple therapy for heart failure before and after electronic cardiac device implantation - are we hitting our targets?

Abstract Background Quadruple therapy is currently recommended pharmacological treatment for heart failure with reduced ejection fraction (HFrEF). It consists of beta-blockers, mineralocorticoid receptor antagonists (MRA), angiotensin converting enzyme inhibitors (ACE-I) – recently suggested to be replaced with angiotensin receptor/neprilysin inhibitor (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2-I). Patients eligible for implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) implantation should have therapy titrated to evidence-based target doses prior to the procedure, whenever tolerable. Compliance with guidelines as well as distinction in prescription practice before and after device implantation in the era of quadruple HFrEF therapy has not yet been fully researched. Purpose The purpose of this study is to evaluate the use of disease-modifying drugs in corresponding target doses in patients with HFrEF eligible for ICD or CRT implantation, prior to and after the procedure. Methods This is a retrospective observational study which included patients with HFrEF hospitalized for ICD or CRT implantation in a single tertiary centre from January 2021 to January 2023. Data was collected through patients' medical history and phone calls. Results We collected data on a total of 107 patients with HFrEF and ICD or CRT implantation. Most patients received all four classes of guideline-directed therapy before ICD or CRT implantation: beta-blockers (91,6%), MRA (86,0%), ACE-I (31,8%) or ARNI (59,8%) and SGLT2-I (59,8%). Evidence-based target doses were reached for 10,2%, 52,2%, 11,8%, 32,8% and 100% patients receiving beta-blockers, MRA, ACE-I, ARNI and SGLT2i respectively. After hospitalization for device implantation, results pointed to an increase in prescription of beta-blockers (99,1%), MRA (97,2%), and most notably SGLT2-I (87,9%), while more ACE-I (19,6%) were replaced with ARNI (75,7%). Target doses were reached for 19,8%, 72,1%, 28,6%, 37,0%, and 100% patients receiving beta-blockers, MRA, ACE-I, ARNI, and SGLT2-I respectively. Conclusions Most of the examined patients have been receiving all four drug classes prior to device implantation. We noticed a rising trend in recruiting novel heart failure drugs, ARNI and SGLT2-I, after the procedure. However, drug titration was non-compliant with guidelines. There was a slight improvement in up-titration of therapy after the procedure, which could be explained by more common medication adjustments by electrophysiologists during device control sessions as well as better drug tolerability after device implantation. Regardless, a minority of patients received ACE-I, ARNI and beta blockers in target doses. Despite several objective obstacles to adequate administration of disease-modifying drugs, including intolerability and patients’ non-adherence, further effort in up-titrating guideline-directed medical therapy should be applied.Therapy administration practice

Clinical characteristics of patients with cardiac sarcoidosis who were hospitalized for heart failure

Abstract Background Cardiac sarcoidosis (CS) often leads cardiac dysfunction and exacerbates heart failure. However, there are limited data regarding CS patients who were hospitalized for acute heart failure (AHF). Purpose We aimed to compare the patient characteristics and outcomes between patients with CS who were hospitalized for AHF (CS-AHF) and patients with AHF of other etiology. Methods A total of 4,556 hospitalized patients with CS were identified from the Japanese Diagnosis Procedure Combination database from 2012 to 2020. Among them, we analyzed 254 patients who were hospitalized due to AHF. Patient characteristics, prior medical history, medical therapy for heart failure, intensive care management during hospitalization, in-hospital outcomes and rehospitalization within one year after the index hospitalization were compared with general 4,056 hospitalized AHF patients who were enrolled in the Kyoto Congestive Heart Failure registry. Results Patients with CS-AHF were younger (71 [63-78] vs 80 [72-86]) and more women (69% vs 45%; p &amp;lt; 0.001) than general AHF patients. In addition, CS-AHF were associated with lower prevalence of hypertension, diabetes and dyslipidemia (46% vs 72%, p &amp;lt; 0.001; 28% vs 37%, p = 0.005; and 21% vs 38%, p &amp;lt; 0.001), and lower prescription of angiotensin converting enzyme inhibitors or angiotensin II receptor blocker (28 % vs 46%; p &amp;lt; 0.001) while prescription of beta-blockers were similar between the groups. The length of hospital stay was significantly longer in CS-AHF (23 [14-39] days vs 16 [11-25] days), more patients were treated by intensive respiratory care (32% vs 25%; p = 0.05) and cardiac resynchronization therapy defibrillator (CRTD) implantation (6% vs. 0.5%; p &amp;lt; 0.001) Although in-hospital mortality was similar between the groups, the rate of rehospitalization within one year was higher in CS-AHF (51% vs 39%; p = 0.001). Conclusions Patients with CS-AHF were younger, more women and had lower cardiovascular risk factors than those with AHF in general. CS-AHF were associated with longer hospital stay, higher rate of CRTD implantation and higher rehospitalization rates. More attention might be needed for this distinct group of patients.

ACEi/ARB after STEMI: prognostic impact and predictors of adherence, results from the real-world FAST STEMI registry

Abstract Background The impact of adherence to angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) in real-world patients is understudied. Purpose To identify predictors of lower compliance to ACEi/ARBs and estimate its impact on cardiovascular outcomes and mortality in the first year after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of bought tablets in pharmacies to the expected tablets at 1 year and on total follow-up length. A total of 6043 patients with STEMI from 2012 to 2017 were enrolled in the FAST-STEMI registry and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events and ischemic stroke. The optimal compliance cutoff was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated at univariate and multivariate analysis with logistic regression. Results A total of 4167 patients with ACEi/ARBs prescription at discharge were considered: mean age was 64 ± 12 years old, 77.3% were men, 18.4% had hypertension, 12% were diabetic, 3.8% had previous coronary artery disease (CAD), mean ejection fraction (EF) was 49.21%±8.9%. Mean ACEi/ARBs adherence was 84.4% (IQR 57.5-99.8): after univariate and multivariate analysis, predictors of lower compliance were age ³75 years old (OR 0.822, 95%CI 0.697-0.970) and known ischemic cardiopathy (OR 0.592, 95%CI 0.422-0.831), whereas preserved EF (OR 1.197, 95%CI 1.048-1.368), hypertension (OR 1.339, 95%CI 1.114-1.609) and beta-blockers prescription at discharge (OR 1.442, 95%CI 1.155-1.802) were predictors of good adherence. ACEi/ARBs compliance higher than 72.06% (identified at Youden’s analysis as best cut-off) was found both at univariate and multivariate analysis as a predictor of lower cardiovascular (0.3% vs 2.6%, HR 0.17, 95%CI 0.07-0.36, p&amp;lt;0.001) and all-cause mortality (1.5% vs 5.9%, HR 0.34, 95%CI 0.23-0.51, p&amp;lt;0.001). Finally, ACEi/ARBs optimal compliance at 1-year was associated to a reduction of myocardial infarctions (7.7% vs 10.4%, p=0.02), as well as minor bleedings (0.2% vs 0.7%, p=0.01), whilst did not impact on ischemic stroke nor major bleedings. Conclusions In our large real-world registry, good adherence to ACEi/ARBs therapy after acute myocardial infarction with ST-elevation was associated with a reduction in mortality (either cardiovascular and all-cause), myocardial infarctions and minor bleedings. Older age and previous coronary artery disease resulted as predictors of poor compliance to ACEi/ARBs therapy.

Beta-blockers after STEMI: prognostic impact and predictors of adherence, results from the real-world FAST-STEMI registry

Abstract Background The impact of beta-blocker therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) is debated. Adherence to beta-blockers after acute myocardial infarction and effect on long term cardiovascular outcomes are also fields with significant knowledge gaps. Purpose To identify predictors of lower compliance to beta-blocker therapy and estimate its impact on cardiovascular outcomes and mortality during the first year of follow-up after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of tablets bought in pharmacies to the expected number of tablets needed at 1 year and at the final follow-up. A total of 6043 patients with STEMI were enrolled in the FAST-STEMI registry from 2012 to 2017 and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events, and ischemic stroke. The best compliance cut-off was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated in univariate and multivariate analyses with logistic regression. Results A total of 4992 patients with beta-blockers prescription at discharge were enrolled: mean age was 64±12.3 years old, 76% were male, mean ejection fraction was 49±8.8%. Mean adherence to beta-blockers was 95,8% (IQR 82.2-100). After univariate and multivariate analyses, age over 75 years old (OR 0.76, 95%CI 0.63-0.91) and previous coronary artery disease (OR 0.62, 95%CI 0.44-0.87) resulted as predictors of lower compliance, whereas concomitant ACEi/ARB prescription at discharge was a predictor of good adherence (OR 1.23, 95%CI 1.04-1.46). Adherence to beta-blockers higher than 65.68% (identified as best cut-off at Youden’s analysis) was related to a lower cardiovascular (0.65% vs 1.49%, p 0.009) and all-cause mortality (1.98% vs 4.48%, p &amp;lt;0.001). At multivariate analysis, adherence to beta-blockers was significantly associated with lower cardiovascular mortality (HR 0.40, 95%CI 0.20-0.81, p 0.01) as well as EF &amp;gt;50% (HR 0.30, 95%CI 0.14-0.63, p 0.002), while age over 75 years old (HR 4.72, 95%CI 2.23-9.98, p &amp;lt;0.001) and history of atrial fibrillation (HR 2.63, 95%CI 1.02-6.80, p 0.04) were associated with a higher risk of cardiovascular death. Finally, optimal adherence to beta-blockers did not reduce the number of myocardial infarctions, strokes, or bleeding events. Conclusions In our large real-world registry, optimal adherence to beta-blockers after STEMI was associated with a reduction in both cardiovascular and all-cause mortality. Older age and previous coronary artery disease resulted as predictors of poor compliance to beta-blocker therapy.Kaplan Meier on all-cause and CV deathMultivariate analysis on CV death

Home hospital heart failure admissions are an opportunity to initiate goal directed medical therapy - a retrospective analysis

Abstract Background There is growing recognition of the importance of goal directed medical therapy (GDMT) initiation for heart failure (HF) during hospitalization. Home hospital provides traditional inpatient hospital care in the patient’s home. Data describing GDMT initiation in home hospital is lacking. Purpose We described the rate of GDMT prescription on admission to and on discharge from home hospital for HF exacerbations, and compared the rate of sodium/glucose cotransporter-2 inhibitors (SGLT2i) prescription before and after home hospitalization. Methods This retrospective cohort is derived from all HF hospitalizations in two home hospital programs in the US between February 2020 and October 2022. Patients with heart failure with reduced ejection fraction (HFrEF; EF &amp;lt;50%) and patients with heart failure with preserved ejection fraction (HFpEF) who were hospitalized after February 2022 (when the FDA approved SGLT2i for HFpEF) were included. Exclusion criteria were if care was escalated to the traditional hospital setting, if patient goals of care were comfort care only, or if patients were receiving palliative inotropes. We report the rate of GDMT prescription immediately prior to home hospital admission and at discharge. GDMT for HFrEF was defined as beta-blocker, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and SGLT2i; for HFpEF, only SGLT2i were considered. For the entire cohort, McNemar’s chi-squared test was performed to compare the rate of SGLT2i prescription before and after admission. Other GDMT therapies were not compared due to insufficient power. Reasons for not initiating GDMT are reported. Data were collected through manual chart review. Results We studied 173 hospitalizations; 95 patients had HFrEF and 78 had HFpEF. Mean age was 77.3 years; 65% had atrial fibrillation, 57% had diabetes mellitus, and 51% had chronic kidney disease. For patients with HFrEF, rates of beta-blocker, ACEi/ARB, ARNI, MRA, and SGLT2i prescription on admission were 88%, 56%, 16%, 34%, and 14% and on discharge were 85%, 49%, 17%, 35%, and 23% respectively; Figure 1. For the entire cohort – patients with HFrEF or HFpEF, the difference between the rate of SGLT2i prescription before and after the admission was statistically significant (12.1% vs 20.8%, p-value &amp;lt; 0.001); Figure 2. In 89% of hospitalizations GDMT was not initiated; the three most common reasons were no reason cited (68%), deferral to outpatient follow-up (14%), and kidney dysfunction (10%). Conclusion Home hospital admission for HF represents a feasible opportunity to initiate GDMT. Patients admitted to home hospital for HF had a statistically significant increase in the rate of SGLT2i prescription, although the overall rate remained low. Future study will investigate if GDMT prescription rates are improved with cardiology e-consultation in home hospitalizations.GDMT Prescription Rate - Reduced EFSGLT2i Prescription Rate

Impact of chronic obstructive pulmonary disease on the natural history of atrial fibrillation: a report from the GLORIA-AF registry phase II &amp; III

Abstract Background The relationship between chronic obstructive pulmonary disease (COPD) and atrial fibrillation (AF) remains unclear. COPD may influence the management and prognosis of AF and may affect treatments, including beta-blockers prescription. Purpose To investigate the association between COPD and AF, and assess the impact of COPD on treatment patterns and major adverse outcomes in a large contemporary global cohort of AF patients. Methods The GLORIA-AF Registry enrolled newly diagnosed AF patients with at least 1 stroke risk factor. Diagnosis of COPD and treatments (including oral anticoagulant [OAC]) prescribed were recorded by investigators at baseline. We evaluated clinical characteristics associated with the diagnosis of COPD at baseline, OAC and other treatment prescription, and risk of OAC discontinuation. Adjusted Cox-regression models were utilized to analyse the relationship of COPD with major outcomes including a primary composite outcome of all-cause death and major adverse cardiovascular events (MACE). Results 36,263 patients (mean age 70.1±10.5 years, 45.3% females) were included in this analysis. Patients with COPD (n=2,261, 6.2%) were older, and had higher thromboembolic risk. Increasing age, smoking status, BMI and cardiovascular comorbidities were associated with higher odds of COPD diagnosis at baseline. COPD was associated with higher odds of receiving OACs (Odds Ratio [OR] and 95% Confidence Interval [CI]: 1.31, 1.15-1.49), and with a higher risk of discontinuing OACs during follow-up (hazard ratio (HR): 1.14, 95%CI: 1.03-1.27). COPD patients were more likely prescribed with digoxin and verapamil or diltiazem, with lower prescription of beta-blockers (OR [95%CI]: 0.79, 0.72-0.87; Figure 1) and amiodarone (OR [95%CI]: 0.83, 0.73-0.96). Patients with COPD were at higher risk of the primary outcome of all-cause death and MACE (Hazard Ratio [95%CI]: 1.78, 1.58-2.01; Figure 2), and were also found at higher risk of all-cause mortality, cardiovascular death, MACE and major bleeding, while no statistically significant differences were observed for thromboembolism. There was no statistically significant interaction between beta-blocker use and risk of the primary composite outcome in COPD patients. Conclusions COPD is associated with different treatment patterns in AF patients, higher risk of OAC discontinuation, and ultimately a poorer clinical prognosis, with an increased risk of all-cause death, MACE and major bleeding. Beta-blocker use appeared safe in COPD patients.Figure 1Figure 2

The effect of discontinuing long-term beta-blockers following acute myocardial infarction in optimally treated, stable patients without heart failure - a Danish, nationwide cohort study

Abstract Aims We studied the effect of discontinuing beta-blockers following myocardial infarction in optimally treated, stable patients without heart failure. Methods and results Using nationwide registers, we identified first-time myocardial infarction patients treated with beta-blockers following percutaneous coronary intervention or coronary angiography. The analysis was based on landmarks selected as 1, 2, 3, 4, and 5 years after the first redeemed beta-blocker prescription date. The outcomes included all-cause death, cardiovascular death, recurrent myocardial infarction, and a composite outcome of cardiovascular events and procedures. We used logistic regression and reported standardized absolute 5-year risks and risk differences at each landmark year. Among 21,220 first-time myocardial infarction patients, beta-blocker discontinuation was not associated with an increased risk of all-cause death, cardiovascular death, or recurrent myocardial infarction compared with patients continuing beta-blockers (landmark year 5; absolute risk difference [95% confidence interval]), correspondingly; -4.19% [-8.95%; 0.57%], -1.18% [-4.11%; 1.75%], and -0.37% [-4.56%; 3.82%]). Further, beta-blocker discontinuation within two years after myocardial infarction was associated with increased risk of the composite outcome but there was no risk difference associated with discontinuation hereafter. Conclusion Discontinuation of beta-blockers one year or later after myocardial infarction without heart failure was not associated with increased serious adverse events.