Krantz Mori J, Havranek Edward P, Haynes Deborah K, Smith Inez, Bucher-Bartelson Becki, Long Carlin S
Department of Medicine, Cardiology Division at Denver Health Medical Center and the University of Colorado Health Sciences Center; Colorado Prevention Center, Denver, Colorado, USA.
J Card Fail. 2008 May;14(4):303-9. doi: 10.1016/j.cardfail.2007.12.008.
Predischarge beta-blocker initiation in hospitalized patients with heart failure due to reduced left ventricular ejection fraction (LVEF) is safe and improves adherence; improved outcomes with this approach have not been demonstrated in a randomized trial. This study compared 6-month rehospitalization rates among patients assigned to predischarge beta-blockade coupled with postdischarge nurse management (intervention) versus usual care.
We randomized 64 patients with an LVEF </=0.40 to low-dose carvedilol coupled with nurse management or usual care. The nurse manager saw patients within 2 weeks of discharge, then biweekly until stable. Baseline characteristics reflected a vulnerable population (80% uninsured, 72% minorities, 80% unemployed or disabled), as did heart failure etiology (28% substance abuse, 27% ischemic, 19% hypertension, 17% idiopathic). Mean baseline LVEF was 0.23 in both groups. Among intervention patients at 6 -months, beta-blocker utilization was higher (96 vs. 48%, P < .001), mean New York Heart Association class improved (-1.44 vs. -0.77, P = .01), and total heart failure rehospitalizations were reduced by 84% (3 vs. 19, P = .02). A trend toward improved LVEF was also observed (+16 vs. +11 units, P = .17).
Inpatient beta-blocker initiation coupled with nurse management improved outcomes among sociodemographically disadvantaged heart failure patients. Our results support a practice shift toward inpatient beta-blocker initiation with structured outpatient follow-up.
对于因左心室射血分数（LVEF）降低而住院的心力衰竭患者，出院前开始使用β受体阻滞剂是安全的，并且能提高依从性；但在一项随机试验中尚未证实这种方法能改善预后。本研究比较了出院前接受β受体阻滞剂治疗并联合出院后护士管理（干预组）与常规治疗的患者6个月内的再住院率。
我们将64例LVEF≤0.40的患者随机分为低剂量卡维地洛联合护士管理组或常规治疗组。护士管理人员在患者出院后2周内进行访视，然后每两周访视一次，直至病情稳定。基线特征反映了一个弱势群体（80%未参保、72%为少数族裔、80%失业或残疾），心力衰竭病因也是如此（28%药物滥用、27%缺血性、19%高血压、17%特发性）。两组的平均基线LVEF均为0.23。在干预组患者中，6个月时β受体阻滞剂的使用率更高（96%对48%，P<0.001），纽约心脏协会平均分级改善（-1.44对-0.77，P=0.01），心力衰竭再住院总数减少了84%（3次对19次，P=0.02）。还观察到LVEF有改善的趋势（增加16个单位对增加11个单位，P=0.17）。
住院时开始使用β受体阻滞剂并联合护士管理可改善社会人口统计学上处于劣势的心力衰竭患者的预后。我们的结果支持向住院时开始使用β受体阻滞剂并进行结构化门诊随访的实践转变。
