Letters
ity of patients in the EASE cohort had other indication for surgery, this study does not allow comparison of outcome for surgery vs medical therapy. Additional studies to assess the timing of surgery need to consider other potential factors, including specific indication for surgery and its timing related to diagnosis, operative risk, and other clinical factors that may affect whether and when surgery is performed for complicated infective endocarditis. Tahaniyat Lalani, MD, MHS Andrew Wang, MD Author Affiliations: Infectious Disease Clinical Research Program, Bethesda, Maryland (Lalani); Duke University Medical Center, Durham, North Carolina (Wang). Corresponding Author: Tahaniyat Lalani, MD, MHS, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Bldg 3, First Floor, Portsmouth, VA 23708 ([email protected]). Conflict of Interest Disclosures: None reported.
diuretics may simply reflect an oversight, albeit unjustified, in not switching to oral therapy when warranted. A report of the percentage change in loop diuretic dose from admission to discharge would be beneficial. Lastly, although caution should be exercised when initiating β-blocker therapy soon after intravenous inotrope administration, a report of the average initial β-blocker dosage as well as the average length of stay among patients who received inotropes would be valuable to determine if the time frame between inotrope discontinuation and loop diuretic initiation makes initiation of β-blocker therapy justifiable, ideally with a cautious low initial dose. In addition, an analysis of inotrope use would be of interest, since the concomitant administration of β-blockers with milrinone is preferred. Because initiation of low-dose β-blocker therapy in stable patients prior to discharge has revealed favorable mortality effects, a careful assessment of ideal candidates following adherence to performance measures should be realized.
1. Kanafani ZA, Kanj SS, Cabell CH, et al. Revisiting the effect of referral bias on the clinical spectrum of infective endocarditis in adults. Eur J Clin Microbiol Infect Dis. 2010;29(10):1203-1210.
Marta A. Miyares, PharmD, BCPS
2. Gaca JG, Sheng S, Daneshmand MA, et al. Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J Thorac Cardiovasc Surg. 2011;141(1):98-106.
Author Affiliation: Department of Pharmacy, Jackson Memorial Hospital, Miami, Florida.
3. Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466-2473.
Corresponding Author: Marta A. Miyares, PharmD, BCPS, Department of Pharmacy, Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL 33136 ([email protected]). Conflict of Interest Disclosures: None reported.
Caution Warranted When Defining Contraindications in Initiating β-Blocker Therapy To the Editor Dharmarajan and colleagues1 are to be commended for their review of hospitalized patients with acute decompensated heart failure initiated on β-blocker therapy during predefined periods of clinical instability, which showed that at least 40% of those initiated had at least 1 possible contraindication (care in an intensive care unit, administration of intravenous loop diuretic on the day of discharge, or having received an intravenous inotrope during hospitalization). Though the authors of this study attempted to include patients newly started on β-blocker therapy, defined as no β-blocker treatment on hospital days 1 and 2 and initiation of β-blocker therapy by the day of discharge, there are a few aspects of this study that deserve emphasis and further clarification. It would be interesting to note the use of β-blockers prior to hospitalization, as guideline recommendations2 state to continue maintenance therapy if hemodynamically stable and no contraindications exist. The question relates to how many of those categorized as new therapy starts were actually receiving β-blocker therapy prior to admission and inadvertently stopped when they could have continued or at least have a dose reduction. Essentially, grouping those patients in a cohort of those who should have continued treatment would be most fitting. Second, the authors assume that those receiving intravenous loop diuretics on the day of discharge had unresolved volume overload. Depending on physical findings, laboratory levels, and net fluid change at discharge, patients may have indeed achieved optimal volume status, as reflected by a decrease in loop diuretic dose from admission. Continued intravenous loop
1. Dharmarajan K, Masoudi FA, Spertus JA, Li SX, Krumholz HM. Contraindicated initiation of β-blocker therapy in patients hospitalized for heart failure. JAMA Intern Med. 2013;173(16):1547-1549. 2. Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.
In Reply Dr Miyares raises several excellent points, correctly noting that our study sample may include persons receiving β-blocker therapy prior to admission who had treatment temporarily withheld early during hospitalization. Without access to outpatient pharmacy claims, we could not ascertain the proportion of our study sample in this category. However, even in the unlikely scenario that three-quarters of our sample had received β-blocker therapy prior to hospitalization, our findings still imply that many thousands of patients hospitalized for acute heart failure in the United States are initiated on β-blocker treatment despite potential contraindications. In addition, the receipt of β-blocker therapy prior to hospitalization does not imply that reinitiating treatment prior to discharge is necessarily safe. This finding has yet to be demonstrated and would require a large, prospective clinical trial to avoid confounding. Dr Miyares also correctly notes that some patients may receive intravenous diuretics despite euvolemia because of physician oversight. However, there is no evidence that this practice is widespread. Furthermore, a reduction in diuretic dose from the day of admission cannot be assumed to imply that euvolemia has been reached, as Dr Miyares suggests. Dose reduction can occur in multiple settings, including poor hemo-
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JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
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ity of patients in the EASE cohort had other indication for surgery, this study does not allow comparison of outcome for surgery vs medical therapy. Additional studies to assess the timing of surgery need to consider other potential factors, including specific indication for surgery and its timing related to diagnosis, operative risk, and other clinical factors that may affect whether and when surgery is performed for complicated infective endocarditis. Tahaniyat Lalani, MD, MHS Andrew Wang, MD Author Affiliations: Infectious Disease Clinical Research Program, Bethesda, Maryland (Lalani); Duke University Medical Center, Durham, North Carolina (Wang). Corresponding Author: Tahaniyat Lalani, MD, MHS, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Bldg 3, First Floor, Portsmouth, VA 23708 ([email protected]). Conflict of Interest Disclosures: None reported.
diuretics may simply reflect an oversight, albeit unjustified, in not switching to oral therapy when warranted. A report of the percentage change in loop diuretic dose from admission to discharge would be beneficial. Lastly, although caution should be exercised when initiating β-blocker therapy soon after intravenous inotrope administration, a report of the average initial β-blocker dosage as well as the average length of stay among patients who received inotropes would be valuable to determine if the time frame between inotrope discontinuation and loop diuretic initiation makes initiation of β-blocker therapy justifiable, ideally with a cautious low initial dose. In addition, an analysis of inotrope use would be of interest, since the concomitant administration of β-blockers with milrinone is preferred. Because initiation of low-dose β-blocker therapy in stable patients prior to discharge has revealed favorable mortality effects, a careful assessment of ideal candidates following adherence to performance measures should be realized.
1. Kanafani ZA, Kanj SS, Cabell CH, et al. Revisiting the effect of referral bias on the clinical spectrum of infective endocarditis in adults. Eur J Clin Microbiol Infect Dis. 2010;29(10):1203-1210.
Marta A. Miyares, PharmD, BCPS
2. Gaca JG, Sheng S, Daneshmand MA, et al. Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J Thorac Cardiovasc Surg. 2011;141(1):98-106.
Author Affiliation: Department of Pharmacy, Jackson Memorial Hospital, Miami, Florida.
3. Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466-2473.
Corresponding Author: Marta A. Miyares, PharmD, BCPS, Department of Pharmacy, Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL 33136 ([email protected]). Conflict of Interest Disclosures: None reported.
Caution Warranted When Defining Contraindications in Initiating β-Blocker Therapy To the Editor Dharmarajan and colleagues1 are to be commended for their review of hospitalized patients with acute decompensated heart failure initiated on β-blocker therapy during predefined periods of clinical instability, which showed that at least 40% of those initiated had at least 1 possible contraindication (care in an intensive care unit, administration of intravenous loop diuretic on the day of discharge, or having received an intravenous inotrope during hospitalization). Though the authors of this study attempted to include patients newly started on β-blocker therapy, defined as no β-blocker treatment on hospital days 1 and 2 and initiation of β-blocker therapy by the day of discharge, there are a few aspects of this study that deserve emphasis and further clarification. It would be interesting to note the use of β-blockers prior to hospitalization, as guideline recommendations2 state to continue maintenance therapy if hemodynamically stable and no contraindications exist. The question relates to how many of those categorized as new therapy starts were actually receiving β-blocker therapy prior to admission and inadvertently stopped when they could have continued or at least have a dose reduction. Essentially, grouping those patients in a cohort of those who should have continued treatment would be most fitting. Second, the authors assume that those receiving intravenous loop diuretics on the day of discharge had unresolved volume overload. Depending on physical findings, laboratory levels, and net fluid change at discharge, patients may have indeed achieved optimal volume status, as reflected by a decrease in loop diuretic dose from admission. Continued intravenous loop
1. Dharmarajan K, Masoudi FA, Spertus JA, Li SX, Krumholz HM. Contraindicated initiation of β-blocker therapy in patients hospitalized for heart failure. JAMA Intern Med. 2013;173(16):1547-1549. 2. Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.
In Reply Dr Miyares raises several excellent points, correctly noting that our study sample may include persons receiving β-blocker therapy prior to admission who had treatment temporarily withheld early during hospitalization. Without access to outpatient pharmacy claims, we could not ascertain the proportion of our study sample in this category. However, even in the unlikely scenario that three-quarters of our sample had received β-blocker therapy prior to hospitalization, our findings still imply that many thousands of patients hospitalized for acute heart failure in the United States are initiated on β-blocker treatment despite potential contraindications. In addition, the receipt of β-blocker therapy prior to hospitalization does not imply that reinitiating treatment prior to discharge is necessarily safe. This finding has yet to be demonstrated and would require a large, prospective clinical trial to avoid confounding. Dr Miyares also correctly notes that some patients may receive intravenous diuretics despite euvolemia because of physician oversight. However, there is no evidence that this practice is widespread. Furthermore, a reduction in diuretic dose from the day of admission cannot be assumed to imply that euvolemia has been reached, as Dr Miyares suggests. Dose reduction can occur in multiple settings, including poor hemo-
jamainternalmedicine.com
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Calgary User on 05/26/2015
481
