Highlights from

ACC 2019

American College of Cardiology Annual Scientific Session & Expo

New Orleans 16-18 March 2019

Frequent use of beta-blocker after HFpEF hospitalisations in elderly patients without compelling indications

Older adults who suffer from heart failure with preserved ejection fraction (HFpEF) are frequently prescribed beta-blockers despite limited data to show their benefit in HFpEF [1]. Moreover, there is evidence suggesting that these agents can worsen geriatric conditions in this population by exacerbating chronotropic incompetence.

Dr Brian Yum (Weill Cornell Medicine, USA) and colleagues examined a subset of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. REGARDS is an observational, population-based cohort study including 30,000 individuals aged ≥45 years designed to identify factors that contribute to the excess stroke mortality in Southeastern USA and in African Americans. Yum et al. examined 316 adults aged >65 years with an adjudicated HFpEF hospitalisation to gain insights into indications for beta-blockers use among older adults hospitalised with HFpEF. The presence of a history of myocardial infarction (MI), arrhythmia, coronary artery disease (CAD), and hypertension was identified in this group.

Of the total 306 hospitalisations for HFpEF, beta-blockers were prescribed at discharge in 68% of cases. Among hospitalisations resulting in beta-blocker prescriptions, 60% had a compelling indication for beta-blocker use: 44% had arrhythmias and 29% had an MI history. Among the 40% of patients who lacked a compelling indication, 57% had CAD without MI and 38% had hypertension alone (without arrhythmia, MI, or CAD). The researchers emphasised that these are both clinical scenarios that possess little supportive evidence on the benefit of beta-blockers. Among the number of hospitalisations resulting in beta-blocker prescription at discharge, 69% of patients harboured geriatric conditions. No significant differences were observed in the prevalence of geriatric conditions between hospitalisations of individuals with compelling indications for beta-blockers and hospitalisations of individuals with non-compelling indications (see Figure). Two potential limitations of this study were, firstly, that the trial relied on medical record review, which can lead to misclassifications for beta-blocker indications, and, secondly, the reasoning behind the clinician’s decision to prescribe beta-blockers could only be inferred.

Figure: The prevalence of geriatric conditions based on beta-blocker indications [1]

ACC MCR Ch5 table

The authors concluded that beta-blockers are commonly prescribed following HFpEF hospitalisations among older adults in the absence of compelling indications, even in the case of geriatric conditions being present. This is a reason for concern as beta-blockers can worsen function in patients with geriatric conditions and can increase their risk for adverse drug reactions. Therefore, future studies are needed to identify the underlying reasons for prescribing beta-blockers in patients with HFpEF and to develop strategies to limit their use among those individuals who may experience harm.

The content and interpretation of these conference highlights are the views and comments of the speakers/authors.