Primary prevention of heart failure: an update.

PURPOSE OF REVIEW: The prevalence of heart failure is increasing world-wide. Primary prevention is essential. There are no trials targeting primary prevention. This review will focus on recently published studies that support drug therapy and lifestyle modification of high risk patients. RECENT FINDINGS: Recent meta-analyses confirm the beneficial effect of ACE-inhibitors, angiotensin-receptor blockers, and diuretics and/or beta blockers in the prevention of heart failure. However, heart failure is increased in patients receiving calcium channel blockers when compared with those receiving ACE-Is and beta blockers. High adherence to antihypertensive therapy results in a significant reduction in heart failure. Targeting a systolic blood pressure of less than 120 mmHg compared with less than 140 mmHg in diabetic hypertensive patients does not appear to decrease the development of heart failure. Not smoking, maintaining a healthy weight, performing regular exercise, and maintaining a healthy diet decrease the incidence of heart failure. SUMMARY: Utilization of antihypertensive agents appears to be the best global strategy for the prevention of heart failure. ACE-inhibitors and angiotensin-receptor blockers remain excellent first line agents. A large proportion of heart failure risk is due to modifiable factors, which need to be identified and controlled. Smoking confers up to a two-fold risk for the development of heart failure in the elderly and should be aggressively targeted.

Comparative effectiveness of beta-blockers in elderly patients with heart failure.

BACKGROUND: Whether beta-blockers (BBs) other than carvedilol, metoprolol succinate, and bisoprolol fumarate (evidence-based beta-blockers [EBBBs]) improve survival in patients with heart failure (HF) is unknown. We compared the effectiveness of EBBBs vs non-EBBBs on survival. METHODS: Our study population included North Carolina residents at least 65 years old who were eligible for Medicare and Medicaid with pharmacy benefits and had had at least 1 hospitalization for HF during the period 2001 through 2004. Primary outcome was survival from 30 days to 1 year. Secondary outcomes included number and days of rehospitalizations for HF and number of outpatient visits. Cohorts were defined by BB class (EBBBs, non-EBBBs, or no BBs) in first 30 days after discharge from index hospitalization for HF. Outcomes were analyzed using inverse probability-weighted (IPW) estimators with propensity score adjustment. RESULTS: Of 11,959 patients, 40% were nonwhite, 79% were female, and 26% were at least 85 years old. Fifty-nine percent received no BB, 23% received EBBBs, and 18% received non-EBBBs. One-year adjusted mortality rates were 28.3% (no BBs), 22.8% (non-EBBBs), and 24.2% (EBBBs). The IPW-adjusted comparisons of 1-year mortality outcomes for either non-EBBBs or EBBBs compared with no BBs were statistically significant (P = .002 for both), but there was no statistical difference between the 2 BB groups (P = .43). The IPW-adjusted mean numbers of rehospitalizations for HF were 0.33 (no BBs), 0.29 (non-EBBBs), and 0.41 (EBBBs), with statistically more rehospitalizations in patients receiving EBBBs compared with no BBs (P = .002) and with non-EBBBs (P < .001). CONCLUSION: In this elderly population, the comparative effectiveness of EBBBs vs non-EBBBs was similar for 1-year survival, whereas the rehospitalization rate was higher for patients receiving EBBBs.