The association between beta‐blockers and outcomes in patients with heart failure and concurrent Alzheimer's disease and related dementias

Abstract

Background Contemporary patients with heart failure with reduced ejection fraction (HFrEF) are older and have a higher prevalence of cognitive impairment than those studied in trials. The risk/benefit trade‐off of routine beta‐blocker (BB) use in patients with HFrEF and Alzheimer's disease and related dementias (ADRD) has not been explored. This study aimed to determine the association between BB use and outcomes among patients with HFrEF and ADRD. Methods Using a random 40% sample of Medicare Parts A, B, and D data we identified patients with ≥1 hospitalization for HFrEF between 2008 and 2018. Each patient was classified based on BB use prior to admission and after discharge. Outcomes include 90‐day and 1‐year mortality and readmission. Results Between 2008 and 2018, we identified 357,030 patients hospitalized with HFrEF; 12.7% had ADRD. Patients with HFrEF and ADRD had higher 90‐day and 1‐year mortality compared to patients with HFrEF‐only. Among patients admitted on a BB, 60.5% of patients with HFrEF‐only were continued on therapy after discharge, compared to 56.8% of patients with HFrEF and ADRD. Discontinuing BB was associated with a 2.2‐fold higher risk of 90‐day mortality (p < 0.001) among patients with HF‐only and a 2.‐ fold higher risk of 90‐day mortality (p < 0.001) among patients with HFrEF + ADRD. Not starting a BB was associated with a 1.8‐fold higher risk of 90‐day mortality (p < 0.001) among patients with HFrEF‐only and a 1.7‐fold higher risk of 90‐day mortality (p < 0.001) among patients with HFrEF + ADRD. Similar risks were seen at 1 year. Conclusions BB therapy is associated with significantly lower short and long‐term mortality rates among all patients with HFrEF; the magnitude of these associated benefits appear at least as large in patients with HFrEF and ADRD compared to patients with HFrEF‐only.

The effect of down-titration and discontinuation of heart failure pharmacotherapy in older people: a systematic review and meta-analysis

“…Ten observational studies 10,25,37,[39][40][41][42][43][44] (n=363,784) reported similar findings in people with HFpEF 43 but increased risk in HFrEF. Discontinuation of beta-blockers in hospitalised HFrEF patients with ADHF showed 2-fold risk of mortality (RR 2.06, 95%CI 1.31-3.24, five-studies, n=178,849, I 2 =69%, very low-quality evidence, eFigure 4b) 25,39,41,42,44 and 7% increased risk of 1-year readmission compared to continuation (HR 1.07, 95%CI 1.02 to 1.13, 2-studies, n=357,782, I 2 =3%, moderate-quality evidence, Figure 2) 40,44 and no statistical difference in risk of 8-52-week hospitalisation (RR 1.00, 95% CI 0.84 to 1.19, four-studies, n=362,136, I 2 =69%, very low-quality evidence, eFigure 6b) 25,40,41,44 . ADWEs included ventricular arrythmia (n=8, 5%), AF (n=44, 3%), acute coronary artery syndrome (n=12, 8%) and syncope (n=3, 2%); but no significant change in activities of daily living (ADLs).…”

Acute Myocardial Infarction and Risk of Cognitive Impairment and Dementia: A Review

“…A study of 357,030 patients hospitalised with heart failure with reduced ejection fraction (HFrEF) found that the benefit of BB in reducing mortality in HFrEF is at least maintained in patients with dementia [ 254 ]. Another prospective cohort study also did not find any association between BB use and delirium [ 255 ].…”