Dosing of Beta-Blocker Therapy Before, During, and After Hospitalization for Heart Failure (from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure)

Heart failure (HF) guidelines recommend that β blockers be titrated to achieve the target doses shown to be effective in major clinical trials, if tolerated. Little is known, however, regarding the doses of β blockers used in patients with HF in routine clinical practice before, during, and after hospitalization for HF. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) enrolled 5,791 patients admitted with HF in a registry with prespecified 60- to 90-day follow-up at 91 academic and community hospitals throughout the United States. Among 2,373 patients with systolic HF eligible for β blockers at discharge, 1,350 (56.9%) were receiving β-blocker therapy before admission and continued on therapy, and 632 (26.6%) were newly started. The mean total daily dose for β blockers before hospital admission was <1/2 the recommended target dose (carvedilol 21.5 ± 17.8 mg and metoprolol succinate 69.2 ± 51.9 mg), with infrequent up- or down-titration during the HF hospitalization. More than 2/3 of patients had no change in their β-blocker doses in the first 60 to 90 days after hospital discharge. At 60- to 90-day postdischarge follow-up, only 17.5% and 7.9% of patients were being treated with recommended target doses of carvedilol and metoprolol succinate, respectively. In conclusion, these data reveal that the doses of β blockers applied in clinical practice are substantially less that the doses achieved in randomized clinical trials in HF and recommended in national guidelines. In the first 60 to 90 days after hospital discharge, little up-titration in β-blocker dosing occurs. Further efforts are needed to help understand and overcome this β-blocker titration gap.