No: 3038

Pre-Discharge Initiation of Carvedilol in Patients Stabilized during an Admission for Decompensated Heart Failure is a Effective Strategy to Improve the Use of Beta-Blocker Therapy: Results of the IMPACT-HF Trial

Keywords: Heart failure, Beta-adrenergic receptor blockers, Outcomes

Author Block: Mihai Gheorghiade, Northwestern University, Chicago, IL; Wendy A Gattis, Dianne S Gallup, Duke Clinical Research Institute/Duke University Medical Center, Durham, NC; A B Chandler, Cardiovascular Associates of Augusta, Augusta, GA; A A Chu, Heart Care MidWest, Peoria, IL; Vic Hasselblad, Christopher M O'Connor; Duke Clinical Research Institute/Duke University Medical Center, Durham, NC


Background: Beta-blockers (BB) are underused in heart failure (HF). Pre-discharge (d/c) initiation may improve the use of evidence based BB.

Objective: IMPACT-HF tested the hypothesis that pre-d/c initiation of carvedilol in patients (pts) hospitalized for worsening HF would increase the number of pts treated with BB at 60 days without increasing side effects or length of stay (LOS).

Methods: IMPACT-HF was a prospective, randomized, open-label, multi-center study of 363 pts hospitalized for worsening HF whose symptoms had been stabilized in preparation for d/c. Pts were randomized to carvedilol initiation pre-d/c or to the standard approach of post-d/c initiation (>2 weeks) of BB at the physician’s discretion. The primary endpoint was the number of pts treated with BB at 60 days. Secondary endpoints included: number of pts discontinuing BB, median dose achieved, and a composite of death or rehospitalization.

Results: Baseline characteristics were similar between the groups.
At 60 days after randomization, 165 (91.2%) pts randomized to pre-d/c carvedilol initiation were treated with a BB as compared to 130 (73.4%) pts randomized to initiation post-d/c at the physician’s discretion (p<0.0001). Pre-d/c initiation was not associated with a statistically significant increased risk of hypotension (1.6% pre-d/c vs. 0.6% post-d/c), bradycardia (1.6% pre-d/c vs. 0% post-d/c), or worsening HF (0.5% pre-d/c vs. 1.7% post-d/c). The median LOS was 5 days in both groups. At 60 days, pts in the pre-d/c carvedilol arm reached 36.3% of the target BB dose, as compared to pts in the physician discretion arm who reached 28.6% of the target BB dose (p=0.02). The composite rate of death + rehospitalization was 25.3%, despite the use of ACE-inhibitors and BB in most pts. The pre-d/c carvedilol initiation group tended to have a lower event rate but the numbers were too small to detect significant differences.

Conclusions: Pre-d/c initiation of carvedilol in stabilized pts hospitalized for HF improved the use of BB at 60-days without increasing side effects or LOS. Pre-d/c initiation may be one approach to improve the use of BB in this population.