Indications for β-Blocker Prescriptions in Heart Failure With Preserved Ejection Fraction

Brian Yum, MD; Alexi Archambault, MPH; Emily B. Levitan, ScD; Tina Dharamdasani, MPH; Jerard Kneifati-Hayek, MD; Joseph T. Hanlon, PharmD, MS; Ivan Diaz, PhD; Mathew S. Maurer, MD; Mark S. Lachs, MD, MPH; Monika M. Safford, MD; Parag Goyal, MD, MSc

Disclosures

J Am Geriatr Soc. 2019;67(7):1461-1466. 

In This Article

Abstract and Introduction

Abstract

Objectives: To better understand indications for β-blocker (BB) prescriptions among older adults hospitalized with heart failure with preserved ejection fraction (HFpEF).

Design/Setting: Retrospective observational study of hospitalizations derived from the geographically diverse Reasons for Geographic and Racial Differences in Stroke cohort.

Participants: We examined Medicare beneficiaries aged 65 years or older with an expert-adjudicated hospitalization for HFpEF (left ventricular ejection fraction = 50% or greater).

Measurements: Discharge medications and indications for BBs were abstracted from medical records.

Results: Of 306 hospitalizations for HFpEF, BBs were prescribed at discharge in 68%. Among hospitalizations resulting in BB prescriptions, 60% had a compelling indication for BB—44% had arrhythmias, and 29% had myocardial infarction (MI) history. Among the 40% with neither indication, 57% had coronary artery disease (CAD) without MI and 38% had hypertension alone (without arrhythmia, MI, or CAD), both clinical scenarios with little supportive evidence of benefit of BBs. Among hospitalizations resulting in BB prescription at discharge, 69% had geriatric conditions (functional limitation, cognitive impairment, hypoalbuminemia, or history of falls). There were no significant differences in the prevalence of geriatric conditions between hospitalizations of individuals with compelling indications for BBs and hospitalizations of individuals with noncompelling indications.

Conclusions: BBs are commonly prescribed following a hospitalization for HFpEF, even in the absence of compelling indications. This occurs even for hospitalizations of individuals with geriatric conditions, a subpopulation who may be at elevated risk for experiencing harm from BBs.

Introduction

Heart failure with preserved ejection fraction (HFpEF) affects over 3 million adults in the United States, accounting for 50% of all episodes of HF.[1] While several medications, including β blockers (BBs) and renin-angiotensin inhibitors, have yielded improved outcomes in HF with reduced ejection fraction (HFrEF) and are key pillars of its management,[2] no medications have consistently improved outcomes in HFpEF.[3] Despite lack of data supporting their benefits, medications commonly used for HFrEF, such as BBs, are frequently prescribed for HFpEF.[4,5] Indeed, in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist study, almost 80% of participants with HFpEF took BBs.[4]

There is cause for concern regarding the use of BBs in adults with HFpEF. Not only have they failed to improve clinical end points in randomized controlled trials (RCTs),[6–8] but BBs may actually cause harm in HFpEF through a number of potential mechanisms. First, they can exacerbate chronotropic incompetence, which is defined as the inability to increase one's heart rate commensurate with physiologic need and is a common physiologic mechanism underlying HFpEF.[9,10] Second, BBs are a common cause of adverse drug reactions.[11] Third, BBs can worsen function in the setting of geriatric conditions,[12] an important consideration for HFpEF, which is a condition that disproportionally affects older adults.[13] Given the high prevalence of BB use in HFpEF despite the paucity of data to support its benefit and the presence of several potential mechanisms for causing harm, we sought to examine hospitalizations for HFpEF in an unselected national cohort of older adults to better understand indications for BB prescriptions in HFpEF. We hypothesized that BB prescriptions would be common even in the absence of compelling indications.

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