Opportunities for treatment optimization with beta-blockers, ivabradine often missed in HF clinic

Most HF patients with reduced ejection fraction treated at a community HF clinic received beta-blocker therapy to maintain a heart rate <70 bpm, but relatively few require beta-blocker up-titration or ivabradine initiation, results of a new study suggest.

Researchers evaluated 1,000 consecutive follow-up appointments at a HF specialist clinic in the United Kingdom from January to July 2013. The cohort included 824 patients with HF (555 men; mean age, 74 years) who were treated according to standardized protocol at each visit. Patients were grouped according to left ventricular ejection fraction: reduced (≤35%; n=202), intermediate (36% to 49%; n=252) or normal (≥50%; n=370).

Eligibility for either treatment with ivabradine or beta-blocker optimization was assessed according to the European Society of Cardiology and UK National Institute for Health and Care Excellence (NICE) guidelines.

Among patients with reduced LVEF, 94% were receiving beta-blockers and 4% were receiving ivabradine. Patients in sinus rhythm had a mean heart rate of 68 ± 12 bpm. One-third of the patients in this group were receiving the maximum guideline-indicated beta-blocker dose or higher, and 60% were receiving 50% of the maximum dose or higher. Similar beta-blocker and ivabridine prescription rates were observed in the intermediate LVEF group. Among patients with normal LVEF, 78% were treated with beta-blockers and 2% with ivabradine.

Across 70 clinic visits, 58 patients with reduced EF had a heart rate ≥70 bpm and sinus rhythm. Among 33 patients eligible for up-titration of beta-blockers according to ESC guidelines, 13 received up-titration during their visit. Among 25 patients who were either receiving the maximally tolerated dose of beta-blockers or were intolerant to the therapy, and consequently were eligible for ivabradine according to the ESC guidelines, 14 did not begin treatment at the visit and one did not receive a potential dose increase.

Analysis according to the NICE guidelines indicated 32 patients with LVEF <35%, sinus rhythm and a heart rate ≥75 bpm. Of those, eight of 18 patients eligible for beta-blocker optimization did not receive it, whereas initiation of ivabradine did not occur in eight of 14 eligible patients.

“The opportunity to intervene to optimize treatment is still often missed, even in an expert clinic,” the researchers concluded. “Education and audit should increase awareness among physicians about the importance of managing heart rate in patients with left ventricular systolic dysfunction and sinus rhythm.”

Disclosure: The researchers report receiving departmental research support from Servier.

Source: www.healio.com