While the guideline for the management of heart failure (HF) with reduced ejection fraction (HFrEF) recommends titrating the dose of beta-blockers to the maximum target dose, an analysis of Medicare fee-for-service claims shows that all median doses of beta-blockers were lower than the recommended target dose. “While the care of older adults with HFrEF is highly complex due to multiple geriatric syndromes such as multimorbidity, frailty, or cognitive impairment, most of the clinical trials used for the guideline for the management of HFrEF did not include older adults with such geriatric syndromes,” write the authors. “Therefore, applying a relatively high target dose to real-world older patients may be impractical.”
A 5% sample of claims data with an index claim for a primary care or cardiologist visit for HFrEF in the first 3 quarters of 2015 showed low median doses of all beta blockers. Among 12,336 individuals, the investigators found: “A small proportion of the cohort received at least the target dose beta-blocker (1.68% in total cohort); only 34.60% (82/231) were prescribed with at least the target dose bisoprolol, 0.42% (62/7603) for carvedilol, 26.82% (22/82) for carvedilol CR, and 0.75% (35/4697) for metoprolol succinate.
“The median dose for each age group (65 ~ 74, 75 ~ 84, 85 ~ 94, and +95) for bisoprolol was 5, 5, 5, and 10 mg (P-value for trend 0.30), for carvedilol, 25, 12.5, 12.5, and 12.5 mg (P-value <0.01), for carvedilol CR, 40, 40, and 40 mg (no patients in +95 age group, P-value 0.23), and for metoprolol succinate, 50, 50, 50, and 37.5 mg (P-value <0.01).…”