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Barriers to Beta-Blocker Use and Up-Titration Among Patients with Heart Failure with Reduced Ejection Fraction

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Abstract

Purpose

For patients with heart failure with reduced ejection fraction (HFrEF), guidelines recommend use of beta-blockers with gradual up-titration. However, many patients with HFrEF do not use beta-blockers and up-titration is rare. Our purpose was to identify and rank barriers to beta-blocker use and up-titration from the perspective of primary care physicians.

Methods

We conducted 4 moderated, structured group discussions among 19 primary care physicians using the nominal group technique; 16 participants also completed a survey. Participants generated lists of barriers to beta-blocker use and up-titration among patients with HFrEF. Each participant had six votes with three votes assigned to the item ranked most important, two to the second most important item, and one to the third most important item. Investigators characterized items into themes. The percentage of available votes was calculated for each theme.

Results

Fifteen of 16 participating primary care physicians who completed the survey reported that management of beta-blockers was their responsibility. Treatment/side effects, particularly hypotension, were identified as the most important barrier for beta-blocker use (72% of available votes) followed by polypharmacy (11%), healthcare system barriers (10%), and comorbidities (6%). Barriers to up-titration included treatment/side effects (49% of available votes), patient communication/buy-in (21%), polypharmacy (13%), and healthcare system barriers (8%).

Conclusions

Many barriers to guideline concordant use of beta-blockers among patients with HFrEF identified by primary care providers are not readily modifiable. Addressing these barriers may require development, testing, and dissemination of protocols for beta-blocker initiation and up-titration that are safe and appropriate in primary care.

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Funding

This research, including design and conduct of the study, analysis and interpretation of the data, and preparation of the manuscript, was supported through an academic collaboration between University of Alabama at Birmingham and Amgen Inc. The funders provided comments on the design and interpretation of this work. The academic authors conducted all analyses and maintained the rights to publish this manuscript.

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Authors and Affiliations

  1. Department of Epidemiology, University of Alabama at Birmingham, RPHB 220, Birmingham, AL, 35294-0022, USA

    Emily B. Levitan

  2. Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA

    Melissa K. Van Dyke

  3. Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA

    Matthew Shane Loop

  4. Division of Continuing Medical Education, University of Alabama at Birmingham, Birmingham, AL, USA

    Ronan O’Beirne

  5. General Internal Medicine, Weill Cornell Medicine, New York, NY, USA

    Monika M. Safford

Authors
  1. Emily B. Levitan
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  2. Melissa K. Van Dyke
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  5. Monika M. Safford
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Corresponding author

Correspondence to Emily B. Levitan.

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Conflict of Interest

Drs. Levitan, Loop, O’Beirne, and Safford report research funding from Amgen Inc. Dr. Levitan reports serving on advisory boards for Amgen Inc. and consulting for Novartis. Dr. Van Dyke was employed by Amgen Inc. at the time the research was conducted.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Potential participants were provided a written description of the purpose, risks, and benefits of the study; the voluntary nature of the study was emphasized verbally and in writing. The University of Alabama at Birmingham Institutional Review Board approved this study with a waiver of the requirement to obtained written documentation of informed consent.

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Levitan, E.B., Van Dyke, M.K., Loop, M.S. et al. Barriers to Beta-Blocker Use and Up-Titration Among Patients with Heart Failure with Reduced Ejection Fraction. Cardiovasc Drugs Ther 31, 559–564 (2017). https://doi.org/10.1007/s10557-017-6764-8

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  • DOI: https://doi.org/10.1007/s10557-017-6764-8

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