β-blocker therapy in patients with heart failure in the urban setting: Moving beyond clinical trials

Background Despite their known benefits, β-blockers (BBL) are not yet widely prescribed for heart failure, especially in the primary care setting. We wanted to identify patient characteristics that could guide primary care physicians in deciding whether they or a cardiologist should initiate BBL. A second objective was to determine the tolerability of BBL in clinical practice. Methods A retrospective chart review was conducted on a consecutive series of 551 patients with systolic dysfunction referred to a heart failure clinic in an urban public hospital. Patient responses to BBL were stratified into three categories: favorable (improvement of left ventricular ejection fraction by serial echocardiography), unfavorable (development of decompensated heart failure), or neither. Tolerability of BBL was assessed by the need to permanently discontinue BBL. Results Of 551 patients, 363 (66%) tolerated BBL. Among patients who had BBL initiated in the clinic, 48 had a favorable response, 34 had an unfavorable response, and 57 had neither a favorable or unfavorable response, as defined. A lower systolic blood pressure and higher diuretic dose were associated with development of decompensated heart failure as compared to improvement of ejection fraction. Conclusions A majority of patients with heart failure in an urban public hospital can tolerate BBL. Easily measurable characteristics such as lower systolic blood pressure and higher diuretic dose may assist primary care physicians in triaging patients for referral to cardiologists for β-blocker initiation.