Setting: 91 academic and community hospitals in the United States.
Synopsis: Data was analyzed on 2,373 registry patients with documented LVSD (EF <40) eligible for beta-blocker therapy. During hospitalization, 1,350 patients were continued on beta-blockers, 79 had therapy withdrawn, 303 were not started, and 632 had beta-blockade initiated. Compared with no beta-blocker treatment, adjusted hazard ratio (HR) for death at 60 and 90 days following discharge was lower in patients who were continued on beta-blockade (HR 0.60, 95% CI 0.37–0.99). Compared with continuation of beta-blockade, withdrawal of beta-blockade increased the risk of death (HR 2.3, 95% CI 1.2–4.6).
Results were limited by the observational nature of the study and short follow up. The reason for discontinuation or not starting beta-blockade was not captured in the database, so it is possible sicker patients had beta-blockers discontinued during hospitalization (although the authors attempted to control for this).
Bottom line: Beta-blockers should be continued whenever possible in patients hospitalized for heart failure with LVSD.
Citation: Fonarow GC, Abraham WT, Albert NM, et al. Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure. J Am Coll Cardiol. 2008;52(3):190-199.
Non-invasive Ventilation Does Not Improve Short-term Mortality in Acute Cardiogenic Pulmonary Edema
Clinical question: Does non-invasive ventilation reduce mortality in patients with acute cardiogenic pulmonary edema and are there differences in outcome between use of continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV)?
Background: In patients with acute cardiogenic pulmonary edema, noninvasive ventilation improves physiologic variables and symptoms, decreases rates of invasive ventilation, and may improve mortality.
Study design: Randomized multi center controlled trial.
Setting: 26 district and regional hospitals in the United Kingdom.
Synopsis: 1,156 patients admitted with acute cardiogenic pulmonary edema between July 2003 and April 2007 were randomized to standard oxygen therapy, versus CPAP or NIPPV. There were no significant differences in seven- or 30-day mortality rates between the standard oxygen therapy versus noninvasive ventilation. Mortality at seven days was 9.8% in the standard oxygen group versus 9.5% in the noninvasive ventilation group (P=0.87); 30-day mortality was 16% in the standard oxygen group and 15% in the non-invasive ventilation group (P=0.64). There were no major differences in treatment outcome with NIPPV compared to CPAP.
Although mortality was not decreased, non-invasive ventilation did improve dyspnea and tachycardia within one hour of therapy.
Bottom line: In patients admitted with acute cardiogenic pulmonary edema, noninvasive ventilation improved dyspnea and some physiological parameters, but did not improve short-term mortality rates.
Citation: Gray A, Goodacre S, Newby D, Masson M, Sampson F, Nicholl J. Noninvasive ventilation in acute cardiogenic pulmonary edema. NEJM. 2008;359(2):142-151.
Cyclooxygenase 2 Inhibitors May Increase the Risk of Ischemic Stroke
Clinical question: Do NSAIDs and COX-2 inhibitors increase the risk of ischemic or hemorrhagic stroke?
Background: Selected cyclooxygenase 2 (COX-2) inhibitors have been shown to increase cardiovascular morbidity in a dose-dependent manner and are now used with caution in patients at risk for cardiovascular disease. Little is known about the safety of these medications and non-aspirin, non-steroidal anti-inflammatory drugs (NSAIDS) in those at risk for cerebrovascular disease.
Study design: Retrospective observational cohort study.
Setting: Tennessee Medicaid Program enrollees.
Synopsis: Data was collected from the medical records of 336,906 subjects. Non-users had a baseline stroke rate of 4.51 strokes/1000 person-years. The rate increased to 5.15/1,000 person-years and 5.95/1,000 person-years for rofecoxib and valdecoxib, respectively. Celecoxib and other NSAIDs did not significantly increase the risk of stroke. Analysis of new users of rofexocib and valdecoxib yielded a similarly increased risk of stroke. Most strokes were ischemic.