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Biomedical subjects

Gregg C Fonarow

Publications and source records attributed to Gregg C Fonarow.

At least 55 records · Page 3Linked to original sources
PubMed2005

An approach to heart failure and diabetes mellitus.

Diabetes mellitus is a chronic progressive disease that results in microvascular and macrovascular complications. Diabetes is a significant independent risk factor for heart failure, and there are a substantial number of patients with diabetes and heart failure. Neurohormonal activation plays an important pathophysiologic role in insulin resistance, diabetes, cardiovascular events, and progression of heart failure. Pharmacologic intervention in these neurohormonal systems (ie, angiotensin-converting enzyme [ACE] inhibition, aldosterone antagonism, and beta-adrenergic blockade) has been shown to decrease the morbidity and mortality of diabetes and of heart failure. Despite this knowledge, ACE inhibitors, aldosterone antagonists, and beta-blockers are grossly underutilized, and deaths and hospitalizations due to heart failure have steadily increased. Guidelines for the management of heart failure recommend the use of ACE inhibitors and beta-blockers in patients with mild, moderate, and severe heart failure with or without diabetes. Aldosterone antagonists are recommended in severe heart failure and recent data also support their use in mild to moderate heart failure. Concerns about increased incidence of hypoglycemia, worsening dyslipidemia, and decreased insulin sensitivity with beta-blockers may be preventing physicians from prescribing these agents for their patients with diabetes who have heart failure. Beta-blockade, in conjunction with ACE inhibition and aldosterone antagonism, should be standard therapy for all patients with diabetes and heart failure. Furthermore, every effort should be made to ensure that eligible patients are treated with these evidence-based, guideline-recommended, life-prolonging therapies.

Adrenergic beta-Antagonists↗
PubMed2005

Results of the National Cholesterol Education (NCEP) Program Evaluation ProjecT Utilizing Novel E-Technology (NEPTUNE) II survey and implications for treatment under the recent NCEP Writing Group recommendations.

The most recent national survey of compliance with the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) guidelines was completed before ATP III and showed significant underachievement of low-density lipoprotein (LDL) cholesterol goals. The NCEP Evaluation ProjecT Utilizing Novel E-Technology (NEPTUNE) II was a national survey conducted in 2003. Of the 4,885 patients, 67% achieved their LDL cholesterol treatment goal, including 89%, 76%, and 57%, respectively, in the 0 or 1 risk factor, > or = 2 risk factors or coronary heart disease (CHD), and CHD risk equivalent categories. The percentage with triglyceride concentrations > or = 200 mg/dl (2.25 mmol/L) in each risk category who achieved their LDL cholesterol and non-high-density lipoprotein cholesterol goals was 64%, 52%, and 27%, respectively. Patients with diabetes (55%) and other CHD risk equivalents (40%) were less likely to have achieved their LDL cholesterol targets than those with CHD (62%). Of the 1,447 patients with cardiovascular disease, 75% could be classified as very high risk according to the new July 2004 NCEP Writing Group recommendations, and 17.8% of those at very high risk had an LDL cholesterol level of <70 mg/dl (<1.81 mmol/L). In conclusion, these results suggest improved lipid management compared with previous surveys. The largest treatment gaps were found for features new to ATP III as of July 2004, including goal achievement for patients with CHD risk equivalents and for non-high-density lipoprotein cholesterol targets. Most of those (75%) with cardiovascular disease in NEPTUNE II would be considered very high risk and candidates for aggressive therapy to reach the new optional treatment goals.

Anticholesteremic Agents↗
PubMed2005

Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry.

BACKGROUND: Quality-of-care indicators have been developed for patients hospitalized with heart failure. However, little is known about current rates of conformity with these indicators or their variability across hospitals. METHODS: Data from 81 142 admissions occurring between July 1, 2002, and December 31, 2003, at 223 academic and non-academic hospitals in the United States participating in the Acute Decompensated Heart Failure National Registry (ADHERE) were analyzed. Rates of conformity with the 4 Joint Commission on Accreditation of Healthcare Organizations core performance measures--discharge instructions (HF-1), assessment of left ventricular function (HF-2), use of angiotensin-converting enzyme inhibitors in patients with left ventricular systolic dysfunction (HF-3), and smoking cessation counseling (HF-4)--as well as length of stay and in-hospital mortality rates were computed. RESULTS: Across all hospitals, the median rates of conformity with HF-1, HF-2, HF-3, and HF-4 were 24.0%, 86.2%, 72.0%, and 43.2%, respectively. Rates of conformity at individual hospitals varied from 0% to 100%, with statistically significant differences between academic and non-academic hospitals. Statistically significant positive independent predictors of overall conformity included the prevalence of comorbidities and the use of more intense pharmacologic management. Median hospital length of stay varied from 2.3 to 9.5 days, and in-hospital mortality varied from 0% to 11.1%. CONCLUSIONS: Among hospitals providing care for patients with heart failure, there is significant individual variability in conformity to quality-of-care indicators and clinical outcomes and a substantial gap in overall performance. Establishing educational initiatives and quality improvement systems to reduce this variability and eliminate this gap would be expected to substantially improve the care of these patients.

Aged↗
PubMed2005

In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE).

OBJECTIVES: We sought to compare the in-hospital mortality of patients with acute decompensated heart failure (ADHF) who were receiving parenteral treatment with one of four intravenous vasoactive medications. BACKGROUND: There are limited data regarding the effects of the choice of intravenous vasoactive medication on in-hospital mortality in patients hospitalized with ADHF. METHODS: This was a retrospective analysis of observational patient data from the Acute Decompensated Heart Failure National Registry (ADHERE), a multicenter registry designed to prospectively collect data on each episode of hospitalization for ADHF and its clinical outcomes. Data from the first 65,180 patient episodes (October 2001 to July 2003) were included in this analysis. Cases in which patients received nitroglycerin, nesiritide, milrinone, or dobutamine were identified and reviewed (n = 15,230). Risk factor and propensity score-adjusted odds ratios (ORs) for in-hospital mortality were calculated. RESULTS: Patients who received intravenous nitroglycerin or nesiritide had lower in-hospital mortality than those treated with dobutamine or milrinone. The risk factor and propensity score-adjusted ORs for nitroglycerin were 0.69 (95% confidence interval [CI] 0.53 to 0.89, p < or = 0.005) and 0.46 (94% CI 0.37 to 0.57, p < or = 0.005) compared with milrinone and dobutamine, respectively. The corresponding values for nesiritide compared with milrinone and dobutamine were 0.59 (95% CI 0.48 to 0.73, p < or = 0.005) and 0.47 (95% CI 0.39 to 0.56, p < or = 0.005), respectively. The adjusted OR for nesiritide compared with nitroglycerin was 0.94 (95% CI 0.77 to 1.16, p = 0.58). CONCLUSIONS: Therapy with either a natriuretic peptide or vasodilator was associated with significantly lower in-hospital mortality than positive inotropic therapy in patients hospitalized with ADHF. The risk of in-hospital mortality was similar for nesiritide and nitroglycerin.

Acute Disease↗
PubMed2005

Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis.

CONTEXT: Estimation of mortality risk in patients hospitalized with acute decompensated heart failure (ADHF) may help clinicians guide care. OBJECTIVE: To develop a practical user-friendly bedside tool for risk stratification for patients hospitalized with ADHF. DESIGN, SETTING, AND PATIENTS: The Acute Decompensated Heart Failure National Registry (ADHERE) of patients hospitalized with a primary diagnosis of ADHF in 263 hospitals in the United States was queried with analysis of patient data to develop a risk stratification model. The first 33,046 hospitalizations (derivation cohort; October 2001-February 2003) were analyzed to develop the model and then the validity of the model was prospectively tested using data from 32,229 subsequent hospitalizations (validation cohort; March-July 2003). Patients had a mean age of 72.5 years and 52% were female. MAIN OUTCOME MEASURE: Variables predicting mortality in ADHF. RESULTS: When the derivation and validation cohorts are combined, 37,772 (58%) of 65,275 patient-records had coronary artery disease. Of a combined cohort consisting of 52,164 patient-records, 23,910 (46%) had preserved left ventricular systolic function. In-hospital mortality was similar in the derivation (4.2%) and validation (4.0%) cohorts. Recursive partitioning of the derivation cohort for 39 variables indicated that the best single predictor for mortality was high admission levels of blood urea nitrogen (> or =43 mg/dL [15.35 mmol/L]) followed by low admission systolic blood pressure (<115 mm Hg) and then by high levels of serum creatinine (> or =2.75 mg/dL [243.1 micromol/L]). A simple risk tree identified patient groups with mortality ranging from 2.1% to 21.9%. The odds ratio for mortality between patients identified as high and low risk was 12.9 (95% confidence interval, 10.4-15.9) and similar results were seen when this risk stratification was applied prospectively to the validation cohort. CONCLUSIONS: These results suggest that ADHF patients at low, intermediate, and high risk for in-hospital mortality can be easily identified using vital sign and laboratory data obtained on hospital admission. The ADHERE risk tree provides clinicians with a validated, practical bedside tool for mortality risk stratification.

Acute Disease↗
PubMed2005

When to initiate beta-blockers in heart failure: is it ever too early?

Overwhelming clinical trial evidence confirms the efficacy and safety of beta-blockers in patients with heart failure (HF) caused by systolic dysfunction. beta-Blockers are recommended in national HF guidelines as standard of care therapy. Yet there is also a large body of evidence demonstrating that the use of beta-blockers for HF is seriously inadequate under conventional care. This HF treatment gap is due, in part, to the persistence of perceptions--despite recent evidence to the contrary--that beta-blocker therapy should be delayed until HF patients have been titrated to target doses of angiotensin-converting enzyme inhibitors and have been stable for at least 2 to 4 weeks after hospital discharge, and that early beta-blocker initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence substantiates that beta-blockers significantly reduce the risk of mortality and morbidity, including hospitalization for worsening HF, and have produced early survival benefits in patients with HF. It has also become evident that in-hospital initiation of life-prolonging cardiovascular therapies, including beta-blockers, has a positive impact on clinical outcomes and on long-term patient compliance. Overwhelming clinical evidence suggests that beta-blockers should be administered to all stable HF patients without contraindication and that this therapy should be initiated as soon as possible to ensure that patients derive early and long-term improvements in clinical outcomes.

Adrenergic beta-Antagonists↗
PubMed2005

Insulin-treated diabetes is associated with a marked increase in mortality in patients with advanced heart failure.

OBJECTIVES: This study aimed to investigate the effect of diabetes and insulin use on survival in a large cohort of patients with advanced heart failure (HF) of multiple etiologies. BACKGROUND: Although diabetes is a well-known risk factor for both systolic and diastolic dysfunction, the impact of diabetes and insulin treatment on prognosis of patients with HF has not been well studied. METHODS: History of diabetes and insulin treatment was assessed in 554 consecutive patients with advanced systolic HF who presented to a single center for HF management and/or transplant evaluation (mean age 52.0 +/- 13.1 years, ejection fraction 24.6 +/- 7.4). Patients were stratified into 3 groups based on presence or absence of diabetes and insulin use. Differences in patient characteristics and survival were evaluated. RESULTS: There were 132 patients (23.8%) with diabetes; 43 patients (7.8%) were insulin treated and 89 patients (16.1%) were non-insulin-treated patients with diabetes. The groups were similar in sex, smoking history, medication profile, ejection fraction, body mass index, and serum sodium. Survival at 1 year was 89.7% for nondiabetic patients, 85.8% for non-insulin-treated diabetic patients, and 62.1% for insulin-treated diabetic patients (P < .000 01). After Cox multivariate analysis, insulin-treated diabetes was found to be an independent predictor of mortality (hazard ratio 4.30, 95% CI 1.69-10.94) whereas non-insulin-treated diabetes was not (hazard ratio 0.95, 95% CI 0.31-2.93). Similar findings were seen in clinically relevant subgroups. CONCLUSIONS: Insulin-treated diabetes is associated with a significantly worse prognosis in patients with advanced HF. Further investigations into mechanisms for the association of insulin treatment and mortality in patients with HF are warranted.

Adult↗
PubMed2005

Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE).

BACKGROUND: The ADHERE is designed to study characteristics, management, and outcomes in a broad sample of patients hospitalized with acute decompensated heart failure. Heart failure is a leading cause of hospitalization for adults older than 65 years in the United States. Most available data on these patients are limited by patient selection criteria and study design of clinical trials and single-center studies. METHODS: Participating hospitals identify patients with a primary or secondary discharge diagnosis of heart failure. Medical history, management, treatments, and health outcomes data are collected through review of medical records and entered into a database via secure web browser technology. RESULTS: As of January 2004, data on 107 362 patients have been received from 282 participating hospitals. Of enrollees with available analyzable data (N = 105 388 from 274 hospitals), the mean age was 72.4 (+/-14.0), and 52% were women. The most common comorbid conditions were hypertension (73%), coronary artery disease (57%), and diabetes (44%). Evidence of mild or no impairment of systolic function was found in 46% of patients. Inhospital mortality was 4.0% and the median hospital length of stay was 4.3 days. CONCLUSIONS: The ADHERE demonstrates both the feasibility and significant implications of gathering representative data on large numbers of patients hospitalized with heart failure. Initial data provided important insights into the clinical characteristics and patterns of care of these patients. Ongoing registry work will provide the framework for improved treatment strategies for patients hospitalized with decompensated heart failure.

Aged↗
PubMed2005

Relationship between anemia, cardiac troponin I, and B-type natriuretic peptide levels and mortality in patients with advanced heart failure.

BACKGROUND: Anemia has been associated with worse symptoms and increased mortality in patients with advanced HF. The association between anemia and biomarkers of increased HF risk is unknown. This study aimed to evaluate the relationship between hemoglobin (Hb), cardiac troponin I (cTnI), B-type natriuretic peptide (BNP), and mortality in patients with advanced heart failure (HF). METHODS: A cohort of 264 patients with advanced HF referred to a single university HF center was analyzed. Hb, cTnI, and BNP levels were drawn at time of initial evaluation. Patients were divided into groups based on the presence or absence of anemia, detectable cTnI (> or = 0.04 ng/mL), and elevated BNP (> or = 485 pg/mL). RESULTS: Mean Hb was 13.0 and the values ranged from 7.7 to 17.9 g/dL. Anemic patients were more likely to have elevated BNP (65.7% vs 47.4%, P = .002). Cardiac troponin I levels were detectable in 50.9% and 46.8% of anemic and non-anemic patients, respectively (P = .3). Anemic patients were at 2.3-fold increased risk of mortality (P = .04). Low Hb, detectable cTnI, and elevated BNP remained independent predictors of mortality on multivariate analysis. Anemia in the setting of detectable cTnI, elevated BNP, or both, was associated with markedly increased mortality. CONCLUSIONS: Anemia is associated with elevated BNP and increased mortality in HF. Furthermore, elevation of the cardiac biomarkers, BNP and cTnI, in patients with HF and anemia identifies patients at particularly high risk of future events.

Adolescent↗
PubMed2005

Practical considerations of beta-blockade in the management of the post-myocardial infarction patient.

Acute myocardial infarction (AMI) is a major cause of death and disability in the United States that affects an estimated total of 1.5 million men and women each year. Despite significant advances in pharmacologic and interventional therapies, 25% of men and 38% of women still die within 1 year of the acute event. Beta-blockers have been shown to significantly decrease the risk of morbidity and mortality in patients after an AMI. National guidelines recommend that all patients with AMI may be started on beta-blocker therapy and continued indefinitely, unless absolutely contraindicated or not tolerated. However, a substantial portion of eligible AMI survivors are not prescribed beta-blockers in the hospital after an acute event or upon hospital discharge. In addition, patients with AMI are often treated with agents whose long-term use has not been shown effective and for which optimal dosing has not been defined. This paper will discuss the background of beta-blocker use for the treatment of AMI, discuss the rationale for choosing specific agents, and present protocols for initiating or switching to evidence-based therapies.

Adrenergic beta-Antagonists↗
PubMed2005

Validity of pedometers for measuring exercise adherence in heart failure patients.

BACKGROUND: Measuring adherence to exercise is important to clinicians and researchers because inadequate adherence can adversely affect the effectiveness of an exercise program and cloud the relationship between exercise and clinical outcomes. Hence, assessment strategies for adherence to exercise, as with assessment strategies for other outcomes, must have demonstrated validity if they are to be employed with confidence. We conducted this study to determine the validity of pedometers as a measure of exercise adherence to a home-based walking program in heart failure patients. METHODS AND RESULTS: Exercise adherence was measured using pedometers in 38 patients (74% men) age 54.1 +/- 11.7 years who participated in a 12-month home-based walking program. A comparison of functional status as measured by the 6-minute walk distance and peak oxygen uptake (VO2 max) at 6 months into the exercise training program was made between 2 groups of participants who were thought to represent adherers and nonadherers: participants who demonstrated > or = 10% change in pedometer scores (n = 20) and those who showed no change in pedometer scores (n = 18) from baseline to 6 months. Patients who showed improvements in their pedometer scores over 6 months had better functional status at 6 months (6-minute walk distance 1718 +/- 46 versus 1012 +/- 25 meters, F = 5.699, P = .022; VO 2 max 17 +/- 0.7 versus 10 +/- 0.5 units, F = 7.162, P = .011) when compared with patients whose pedometers reflected minimal change in distance walked (ie, < or = 10%). CONCLUSION: Pedometers are inexpensive and readily available to both clinicians and researchers. The results of this study suggest that they may be a valid indicator of exercise adherence in heart failure patients who participate in a home-based walking program.

Exercise Test↗
PubMed2005

Functional abnormalities in brain areas that mediate autonomic nervous system control in advanced heart failure.

BACKGROUND: Heart failure patients show substantial gray matter loss in brain areas that mediate autonomic control. Those injuries may lead to the aberrant autonomic patterns found in the syndrome. The purpose of this study was to determine if functional responses in the brain to an autonomic challenge would differ from normal patterns and would appear in areas of previously-demonstrated gray matter loss. METHODS AND RESULTS: We subjected 6 heart failure patients (left ventricular ejection fraction 0.15 +/- 0.08; age 49 +/- 12 years) and 16 controls (age 48 +/- 11 years) to a forehead cold pressor challenge that would enhance sympathetic outflow and assessed functional magnetic resonance image signals over the entire brain during a 54-second baseline and 90-second challenge. Application of the cold stimulus elicited aberrant responses in the anterior and posterior hypothalamus, bilateral amygdala, hippocampus, cerebellar cortex, insular cortex, mid/posterior cingulate cortex, right ventral frontal cortex, and temporal and frontal cortices. Many of the areas neighbored or overlaid regions of previously demonstrated gray matter damage. Both classical autonomic control regions, as well as brain areas modulating these sites showed deficient responses, some of which appeared to be of an overdampened or underdampened nature. CONCLUSION: The findings suggest that the earlier demonstrated changes in brain structure in heart failure result in aberrant functional neural responses; these dysfunctions may contribute to progression of the pathology in heart failure.

Adult↗
PubMed2005

Beyond coronary sinus angiography: the value of coronary arteriography and identification of the pericardiophrenic vein during left ventricular lead placement.

OBJECTIVE: The purpose of this study was to define the role coronary arteriography (venous phase) for improving the success of left ventricular (LV) lead implantation and to define the value of identifying the pericardiophrenic vein for optimal LV lead placement in biventricular (bi-v) device implantation. METHODS: Seventy-seven patients underwent bi-v device implantation between July 2002 and October 2003. If the coronary sinus (CS) could not be accessed, then left coronary arteriography was performed during the same procedure. CS access was guided by venous phase images of the coronary arteriogram. The pericardiophrenic vein was identified by selective cannulation or direct visualization. Patients with Cr > 1.5 had gadolinium used as the contrast agent. RESULTS: Seventy-five successful implants were performed (97%). In seven patients (9%) repeated attempts at retrograde cannulation of the CS failed (attempt time 130 +/- 20 minute, mean +/- SD). In these patients, coronary arteriography helped define the location of the CS, which was subsequently successfully cannulated. In six patients the pericardiophrenic vein was identified either during occlusion venography of the CS (postthoracotomy, veno-venous collaterals, n = 2) or during selective cannulation of the pericardiophrenic vein (using a DAIG Csl catheter, n = 4). The vein was directly visualized in three patients who underwent surgical LV lead implantation. LV leads in all these cases were implanted in areas not overlying the preidentified pericardiophrenic vein. During follow-up, none of these patients had evidence of phrenic nerve stimulation. CONCLUSIONS: Intraoperative left coronary arteriography increases the success of CS cannulation. Identification of the pericardiophrenic vein is a useful method to avoid phrenic nerve stimulation.

Contrast Media↗
PubMed2005

In-hospital initiation of statin therapy in acute coronary syndromes: maximizing the early and long-term benefits.

Patients with acute coronary syndrome (ACS) are at high risk for recurrent coronary events, sudden death, and all-cause mortality. Conventional revascularization therapies reduce the risk of further ischemia but do not affect the underlying atherosclerotic disease. Statins have a proven record in the secondary prevention of coronary heart disease. Furthermore, statins have been shown to exert varying degrees of pleiotropic effects, which may stabilize vulnerable atherosclerotic plaques. A compelling body of evidence from randomized controlled trials demonstrates that high-dose, potent statin therapy initiated immediately after an acute coronary event can significantly reduce early as well as longer-term morbidity and mortality. Furthermore, high-dose, potent statin therapy displays a reasonable safety profile. National guidelines now recommend that in patients with ACS, statin therapy should be initiated in hospital prior to discharge, irrespective of baseline low-density lipoprotein cholesterol levels, to improve clinical outcomes. Every effort should be made to ensure all eligible patients with ACS are initiated and maintained on statin therapy.

Angina, Unstable↗
PubMed2005

Strategies to improve the use of evidence-based heart failure therapies.

Patients with heart failure (HF) face a very high risk of hospitalizations, arrhythmias, and mortality. Despite compelling scientific evidence that angiotensin-converting enzyme inhibitors, b-blockers, and aldosterone antagonists reduce hospitalizations and mortality in HF patients, these life-prolonging therapies continue to be underutilized. Recently, device therapy for HF, including implantable cardioverter-defibrillators and cardiac resynchronization devices, has also been demonstrated to result in substantial mortality reduction. A number of studies in a variety of clinical settings have documented that a significant proportion of HF patients are not receiving treatment with these guideline-recommended, evidence-based therapies when guided by conventional care. Treatment gaps in providing other components of HF patient care, including patient education, have also been documented. The demonstration that initiation of cardiovascular protective medications before hospital discharge results in a marked increase in treatment rates, improved long-term patient compliance, and better clinical outcomes has led to the revision of national guidelines to endorse this approach as the standard of care. Recent studies demonstrated that hospital-based systems can improve medical care and education of hospitalized HF patients and accelerate use of evidence-based, guideline-recommended therapies by administering them before hospital discharge. HF disease management programs have also been shown to improve HF treatment, resulting in substantial reduction in hospitalizations and mortality. Further efforts are needed to ensure the implementation of effective strategies and systems that increase the use of evidence-based therapies in the hospital and outpatient settings to reduce the substantial HF morbidity and mortality risk.

Adrenergic beta-Antagonists↗
PubMed2005

The past, present, and future of statin therapy.

Statins are a remarkably safe and efficacious class of medications that have proved to be invaluable in the fight against heart disease. Statins have been prescribed to millions of patients for nearly 20 years; thus there have been hundreds of millions of patient-years of use, with relatively few adverse effects and incalculable benefits. Results from large-scale clinical trials have shown that statins are associated with dramatic decreases in cardiovascular risk. It seems certain that statins will remain a valuable and essential part of the lipid-lowering landscape, but combinations of statins with other lipid-lowering agents are increasingly important. Even with the most potent statins, the desired low-density lipoprotein cholesterol goal might not be attained with statin monotherapy. Furthermore, because of the increasing prevalence of diabetes and the metabolic syndrome, along with their attendant multiple lipid abnormalities, combinations of statins with medications targeted toward multiple lipoprotein particles will emerge.

Cardiovascular Diseases↗
PubMed2004

Importance of in-hospital initiation of evidence-based medical therapies for heart failure-a review.

Patients who have had heart failure (HF) face very high risks of hospitalization and mortality. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors, aldosterone antagonists, and beta blockers decrease rates of hospitalization and mortality in patients who have had HF, these life-prolonging therapies continue to be underused. Many studies in a variety of clinical settings have documented that important numbers of patients who have had HF are not receiving treatment with these evidence-based therapies, which are recommended by national guidelines, when guided by conventional care. This HF treatment gap results from a variety of complex issues, including lack of systems and disease management programs. This gap in beta-blocker therapy may be due in part to persisting perceptions, despite recent evidence to the contrary, that it should be delayed until patients who developed HF have been stable for 2 to 4 weeks after hospital discharge and that its initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence has substantiated that beta blockers can be safely initiated for patients with HF in the hospital and that there are early benefits, including decreased risks of mortality and hospitalization for worsening HF. It has become increasingly evident that in-hospital initiation of evidence-based cardiovascular therapies and patient education have a positive effect on long-term patient compliance and clinical outcomes. Adopting in-hospital initiation of these therapies as the standard of care (in the absence of contraindications or intolerance) in patients who have HF and stabilized systolic dysfunction could substantially improve treatment rates, decrease the risk of future hospitalizations, and prolong life in the large number of patients who are hospitalized each year for HF.

Adrenergic beta-Antagonists↗