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Commencing Volume 19, Issue 1, MedReviews has ceased the publication of this journal. Reviews in Cardiovascular Medicine will continue to be published by IMRPress, Ltd. (www.imrpress.org)

Volume 3, Supplement 3, 2002

Volume 3, Supplement 3, 2002

Table of Contents

The Role of In-Hospital Initiation of Cardioprotective Therapies to Improve Treatment Rates and Clinical Outcomes
Patients with heart failure face a very high risk of hospitalizations and mortality. Despite the compelling scientific evidence that ß-blockers reduce hospitalizations and mortality in patients with heart failure, this lifesaving therapy continues to be underutilized. A number of studies in a variety of clinical settings have documented that a significant proportion of patients with heart failure are not receiving treatment with this guidelinerecommended, evidence-based therapy when guided by conventional care. A similar treatment gap has been documented for lipid-lowering therapy in patients with coronary heart disease. The demonstration that initiation of lipid-lowering and other cardioprotective medications prior to hospital discharge for atherosclerotic cardiovascular events results in a marked increase in treatment rates, improved long-term patient compliance, and better clinical outcomes has led to national guidelines being revised to endorse this approach as the standard of care. In-hospital initiation of ß-blocker therapy for heart failure could be reasonably expected to result in similar improvements in treatment rates and clinical outcomes. Recent data suggest that ß-blockers can be safely and effectively initiated in heart failure patients prior to hospital discharge, and that clinical outcomes are improved. Adopting in-hospital initiation of ß-blocker therapy as the standard of care for patients hospitalized with heart failure could dramatically improve treatment rates and thus substantially reduce the risk of future hospitalizations and prolong life in the large number of patients hospitalized each year. [Rev Cardiovasc Med. 2002;3(suppl 3):S2–S10]
Treatment Gaps in the Pharmacologic Management of Heart Failure
Chronic heart failure continues to increase in incidence and prevalence despite many pharmacologic advances over the previous decade. Morbidity and mortality remain high, with the number of hospitalizations for worsening heart failure in 1999 approaching 1 million. In addition to investigation of new therapies for the treatment of heart failure, attention must be placed on identifying effective methods for increasing the adoption of proven therapies. First, the potential barriers to implementation of evidence-based medicine must be recognized. Subsequently, strategies to overcome such barriers can be developed. Published guidelines may be helpful in educating practitioners on current standards of care. Other tools may also be considered, and testing the influence of such tools on the implementation of optimal therapy may help the scientific community better understand the factors that influence decision-making among clinicians. [Rev Cardiovasc Med. 2002;3(suppl 3):S11–S19]
Beta-Adrenergic Blocking Drugs in Severe Heart Failure
Beta-adrenergic blocking drugs have been shown to improve survival and well-being of patients with mild to moderate heart failure. In more advanced heart failure, the relationship between the short-term hemodynamic support afforded by activation of the sympathetic nervous system and the harm that results from excess sympathetic activation is more complex. Not all studies of ß-adrenergic blocking drugs or antiadrenergic therapy have shown benefit. The Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) trial has revealed that the combined nonselective ß-adrenergic and -adrenergic receptor blocking drug carvedilol produces an important salutary effect on the natural history of advanced heart failure. Mortality was reduced by 35% in the carvedilol group, from an annual (Kaplan-Meier) rate of 18.5% to 11.4%. All-cause hospitalizations were reduced by 20% and hospitalization from heart failure by 33%. Even amongst the subgroups at highest risk, no subpopulation could be identified that did not appear to benefit. The trial supports extending the population of those with chronic heart failure who should be routinely treated with ß-adrenergic blocking drugs (in addition to angiotensin-converting enzyme inhibition therapy) to patients with more advanced disease. [Rev Cardiovasc Med. 2002;3(suppl 3):S20–S26]
Special Clinical Considerations of Beta-Blocker Treatment
Outcomes for heart failure have improved considerably with the implementation of neurohormonal antagonism that includes angiotensin-converting enzyme inhibitors and ßblockers. Despite the robust benefit of ß-blockers for heart failure, it is not clear that the benefit can be extended to all patient groups. Special clinical consideration thus needs to be given to the elderly, women, and African Americans. A retrospective review of available data suggests that despite differences in the natural history of heart failure for these groups, significant benefit can still be expected from the use of ß-blockers for heart failure. Future trials will address these groups in a prospective manner. [Rev Cardiovasc Med. 2002;3(suppl 3):S27–S35]
Hospital-Based Systems to Improve Quality of Care for Heart-Failure Patients
Because much can be done now to block the devastating natural course of heart failure, it is important to understand the role of various treatment paradigms and to institute them in as many patients as possible, with the use of well-constructed practice guidelines to provide common themes for treating specific patients. However, guidelines cannot address all relevant clinical situations, consensus often cannot be reached because evidence is not always available regarding certain therapeutic strategies, and guideline development can be a slow, politically charged, and difficult process. In addition, one must assess compliance with guidelines and the impact of recommendations on outcomes. Continuous quality improvement initiatives in large group practices and hospitals achieve this goal most effectively. Assessment of the impact and accountability with regard to compliance can then be re-related to clinical experience and observation, triggering additional therapeutic developments and strategies that will focus on continued practice improvement. Continuous quality improvement initiatives in the hospital setting have many advantages and are generally seen as good business practice; because of the regulations hospitals are subject to, particularly the linking of payments to hospital accreditation, systems are in place to improve practice patterns. [Rev Cardiovasc Med. 2002;3(suppl 3):S36–S41]
Cost-Effectiveness of Beta-Blocker Treatment in Heart Failure
There is a growing economic burden from the treatment of heart failure that accounts for more than 5% of total health care expenditures. Hospitalization contributes between 60% and 75% of this total expense. The addition of ß-blockers to conventional heart failure therapy results in a significant reduction in hospitalization. As a consequence, ß-blocker therapy in heart failure is very cost-effective and compares favorably to that of other generally accepted medical interventions [Rev Cardiovasc Med. 2002;3(suppl 3):S42–S47]
The Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) Study: Design and Implications
The utilization of -blockers for the treatment of heart failure in the United States is inadequate despite the available data and the current guidelines that support their use. The ongoing Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) study was designed to determine if initiation of ß-blockade prior to hospital discharge is safe and effective in improving the 60-day use of ß-blockers in patients with heart failure. IMPACT-HF is a community-based, multicenter, open-label trial of 375 heart failure patients randomized to carvedilol initiated before their hospital discharge or to usual care (Heart Failure Society of America guidelines that recommend waiting 2–4 weeks after hospitalization for heart failure before initiating ß-blocker therapy). The entry criteria are nonrestrictive to ensure inclusion of patients reflective of the general heart failure population. The primary endpoint of the study is the number of patients treated with any ß-blocker at 60 days. A concurrently ongoing pilot registry will enroll 550 patients, admitted with exacerbated heart failure, in three phases to collect demographic, clinical, treatment patterns, and outcome data. The trial will test the tolerability of ß-blocker initiation in the hospital setting, develop strategies to improve the use of evidence-based medicine in clinical practice, and explore the patient’s course from hospital admission through discharge and up to 60 days. The trial data will determine if in-hospital initiation of ß-blocker therapy is effective at improving the long-term use of pharmacologic agents proven to reduce morbidity and mortality. [Rev Cardiovasc Med. 2002;3(suppl 3):S48–S54]