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The Use of  -Blockers in a Tertiary Care Heart Failure Clinic
Dosing, Tolerance, and Outcomes
Puneeta Tandon, MD;
Finlay A. McAlister, MD, MSc;
Ross T. Tsuyuki, PharmD, MSc;
Marilou Hervas-Malo, MSc;
Ruth Dupuit, BSc;
Justin Ezekowitz, MD;
Bibiana Cujec, MD;
Paul W. Armstrong, MD
Arch Intern Med. 2004;164:769-774.
Background Little is known about the dosing, tolerability, and impact of  -blockers in nontrial participants. This study was conducted to evaluate the use and outcomes of -blockers in a tertiary care heart failure clinic.
Methods Analysis of prospectively collected data from a cohort of 1041 patients with heart failure seen at the University of Alberta Heart Function Clinic, Edmonton, from September 1, 1989, through July 1, 2001, with objective measurement of ejection fraction at baseline and prospective collection of data at all subsequent clinic visits.
Results Median age at baseline was 69 years; 65% were male; 75% had systolic dysfunction; mean ejection fraction was 33%; and 51% had New York Heart Association class III or IV symptoms. Median duration of follow-up was 32 months (interquartile range, 13-62 months). Overall, 46% of patients received -blockers, but only 18% of these were ultimately prescribed the dosages achieved in the trials (mean maximum dosages achieved, 27 mg/d for carvedilol and 81 mg/d for metoprolol tartrate). Of those patients prescribed -blockers, 74% continued to receive them during follow-up. Blood pressure, heart rate, and failure symptomatology did not change appreciably before and after -blockers were prescribed, or during the upward titration of the dosage. Although our patients were prescribed lower dosages than those used in trials, Cox multivariate regression revealed that -blockers were associated with improved survival, even after adjusting for potential confounders including New York Heart Association class, year of prescription, and concomitant medication use (relative risk, 0.63; 95% confidence interval, 0.50-0.81).
Conclusions The benefits of -blockers seen in randomized trials extend to nontrial participants treated in a tertiary care clinic specializing in heart failure. In our cohort of elderly patients with multiple comorbidities, -blockers were well tolerated.
From the Division of General Internal Medicine (Drs Tandon and McAlister), the Epidemiology Coordinating and Research Centre (Drs McAlister and Tsuyuki and Mss Hervas-Malo and Dupuit), and the Division of Cardiology (Drs Tsuyuki, Ezekowitz, Cujec, and Armstrong), University of Alberta, Edmonton. The authors have no relevant financial interest in this article.
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Beta-Blocker Use in a Heart-Failure Clinic
Journal Watch Cardiology 2004;2004:5-5.
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