Why do patients fail to receive B-blockers for chronic heart failure over time? A breal-world Q single-center, 2-year follow-up experience of B-blocker therapy in patients with chronic heart failure Anoop C. Parameswaran, MD, MPH, a W. H. Wilson Tang, MD, b Gary S. Francis, MD, b Ritesh Gupta, MD, c and James B. Young, MD a,b Cleveland, Ohio, and Birmingham, Ala Background The longitudinal pattern of h-blocker use in a heart-failure practice setting has not been explored. Previous studies have not specifically addressed the use of h-blockers over time to determine the rate of use and reasons for discontinuation. The long-term compliance rate for h-blocker drugs outside the context of a clinical trial has not been established. Methods We prospectively followed a cohort of 500 consecutive patients between March and May 2001, with a clinical diagnosis of chronic heart failure seen in a specialized heart failure clinic and determined the longitudinal pattern of h-blocker use and clinical outcomes over a 2-year period. Results The final cohort consists of 340 patients with a complete 2-year follow-up data (mean age 61 F 14 years, 69% men, 53% with ischemic etiology, mean ejection fraction 27.6 F 15%). At 6, 12, and 24 months, h-blocker utilization rates were maintained in 69%, 70%, and 74% of patients, respectively. Of the 120 confirmed initial non–h-blocker users, 28 (23%) were subsequently started on h-blocker, despite suspected relative contraindications in 53% of patients. Over a period of 2 years, the discontinuation rate was 10%, with failure to restart a h-blocker after hospitalization as the most common reason for h-blocker discontinuation. Conclusion Utilization rates of h-blockers in our heart failure clinic have remained constant at approximately 70% throughout a 2-year follow-up. Of those who discontinued h-blockers (10%), the most common documented cause was failure to restart h-blockers after hospitalization. (Am Heart J 2005;149:921- 6.) The use of h-adrenergic blocking therapy (or h- blockers) in chronic heart failure clearly decreases long- term cardiac morbidity and mortality. 1- 4 In the clinical trial setting, h-blockers appear to be well utilized, with up to 88% of patients in studies being maintained on carvedilol 3 or extended-release metoprolol succinate 2 for the duration of the study. In fact, in the MERIT-HF trial, there were no significant differences in the discontinuation rates between metoprolol succinate and placebo. 5 In contrast, data from the SPICE registry and from insurance claims have suggested that h-blocker use in eligible populations may be as low as 30% in clinical practice settings. 6-8 We have previously reported a use rate of 69% in our cohort of patients seen at our heart failure clinic. 9 The objective of this study is to determine the longitudinal pattern of h-blocker use in a busy outpatient heart failure clinic with clinicians employing an aggressive h-blocker titration protocol outside the context of a clinical trial or registry. Methods Study population This is a prospective follow-up study in a cohort of consecutive patients with chronic heart failure seen at a specialized clinic at the Cleveland Clinic Foundation, which has been described previously. 9 This heart failure clinic is a high-volume practice that has adopted an aggressive protocol- based titration of h-blockers in all patients, under the From the a Department of Medicine, and b Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, and c Division of Cardiovascular Medicine, Department of Medicine, University of Alabama at Birmingham, Birming- ham, Ala. This project did not receive any financial support. Drs Tang and Francis are consultants for GlaxoSmithKline Pharmaceuticals; Dr Young is a consultant for AstraZeneca Pharmaceuticals. Submitted April 20, 2004; accepted July 30, 2004. Reprint requests: W.H. Wilson Tang, MD, Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Desk F25, 9500 Euclid Ave, Cleveland, OH 44195. E-mail: tangw@ccf.org 0002-8703/$ - see front matter n 2005, Published by Mosby, Inc. doi:10.1016/j.ahj.2004.07.026