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J Am Coll Cardiol, 2004; 43:1534-1541, doi:10.1016/j.jacc.2003.12.040 © 2004 by the American College of Cardiology Foundation |
,*
* Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
Division of Cardiology, Northwestern University/Feinberg School of Medicine, Chicago, Illinois, USA
Manuscript received August 15, 2003; revised manuscript received November 30, 2003, accepted December 2, 2003.
* Reprint requests and correspondence: Dr. Mihai Gheorghiade, Professor of Medicine, Northwestern University, Feinberg School of Medicine, Galter 10-240, 201 East Huron Street, Chicago, Illinois 60611-2908, USA.
m-gheorghiade{at}northwestern.edu
OBJECTIVES: The Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial was an investigator-initiated study to evaluate if predischarge carvedilol initiation in stabilized patients hospitalized for heart failure (HF) increased the number of patients treated with beta-blockade at 60 days after randomization without increasing side effects or length of hospital stay.
BACKGROUND: Beta-blockers are underused in HF. Predischarge initiation may improve the use of evidence-based beta-blockade.
METHODS: The IMPACT-HF was a prospective, randomized open-label trial conducted in 363 patients hospitalized for HF. Patients were randomized to carvedilol initiation pre-hospital discharge or to postdischarge initiation (>2 weeks) of beta-blockade at the physicians' discretion. The primary end point of the study was the number of patients treated with beta-blockade at 60 days after randomization. Secondary end points included the number of patients discontinuing beta-blockade, median dose achieved, and a composite of death, rehospitalization, unscheduled visit for HF, or 
50% increase in oral diuretic, new oral diuretic, or any intravenous therapy with diuretics, inotropes, or other vasoactive agents.
RESULTS: At 60 days 165 patients (91.2%) randomized to predischarge carvedilol initiation were treated with a beta-blocker, compared with 130 patients (73.4%) randomized to initiation postdischarge (p < 0.0001). Predischarge initiation was not associated with an increased risk of serious adverse events. The median length of stay was five days in both groups.
CONCLUSIONS: Predischarge initiation of carvedilol in stabilized patients hospitalized for HF improved the use of beta-blockade at 60 days without increasing side effects or length of stay. Predischarge initiation may be one approach to improve beta-blocker use in this population.
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