Sunday, March 29, 2015

Obesity and asthma: a unique phenotype

From Current Opinion in Pulmonary Medicine:

Recent findings
Clinical and epidemiological studies indicate that obese patients with asthma may represent a unique phenotype, which is more difficult to control, less responsive to asthma medications and by that may have higher healthcare utilization. A number of common comorbidities have been linked to both obesity and asthma, and may, therefore, contribute to the obese–asthma phenotype. Furthermore, recently published studies indicate that even a modest weight reduction can improve clinical manifestations and outcome of asthma.

Summary
Compared with normal-weight patients, obese and overweight patients with asthma have poorer asthma control and respond less to corticosteroid therapy.

Via Hospital Medicine Virtual Journal Club.

Saturday, March 28, 2015

Risk factors for aortic disease

From a recently published analysis:

Background Community screening to guide preventive interventions for acute aortic disease has been recommended in high‐risk individuals. We sought to prospectively assess risk factors in the general population for aortic dissection (AD) and severe aneurysmal disease in the thoracic and abdominal aorta.

Methods and Results We studied the incidence of AD and ruptured or surgically treated aneurysms in the abdominal (AAA) or thoracic aorta (TAA) in 30 412 individuals without diagnosis of aortic disease at baseline from a contemporary, prospective cohort of middle‐aged individuals, the Malmö Diet and Cancer study. During up to 20 years of follow‐up (median 16 years), the incidence rate per 100 000 patient‐years at risk was 15 (95% CI 11.7 to 18.9) for AD, 27 (95% CI 22.5 to 32.1) for AAA, and 9 (95% CI 6.8 to 12.6) for TAA. The acute and in‐hospital mortality was 39% for AD, 34% for ruptured AAA, and 41% for ruptured TAA. Hypertension was present in 86% of individuals who subsequently developed AD, was strongly associated with incident AD (hazard ratio [HR] 2.64, 95% CI 1.33 to 5.25), and conferred a population‐attributable risk of 54%. Hypertension was also a risk factor for AAA with a smaller effect. Smoking (HR 5.07, 95% CI 3.52 to 7.29) and high apolipoprotein B/A1 ratio (HR 2.48, 95% CI 1.73 to 3.54) were strongly associated with AAA and conferred a population‐attributable risk of 47% and 25%, respectively. Smoking was also a risk factor for AD and TAA with smaller effects.

Friday, March 27, 2015

Unpacking the benefits of almonds

From a recent study:

Methods and Results In a randomized, 2‐period (6 week/period), crossover, controlled‐feeding study of 48 individuals with elevated LDL‐C (149±3 mg/dL), a cholesterol‐lowering diet with almonds (1.5 oz. of almonds/day) was compared to an identical diet with an isocaloric muffin substitution (no almonds/day). Differences in the nutrient profiles of the control (58% CHO, 15% PRO, 26% total fat) and almond (51% CHO, 16% PRO, 32% total fat) diets were due to nutrients inherent to each snack; diets did not differ in saturated fat or cholesterol. The almond diet, compared with the control diet, decreased non‐HDL‐C (−6.9±2.4 mg/dL; P=0.01) and LDL‐C (−5.3±1.9 mg/dL; P=0.01); furthermore, the control diet decreased HDL‐C (−1.7±0.6 mg/dL; P less than 0.01). Almond consumption also reduced abdominal fat (−0.07±0.03 kg; P=0.02) and leg fat (−0.12±0.05 kg; P=0.02), despite no differences in total body weight.

Conclusions Almonds reduced non‐HDL‐C, LDL‐C, and central adiposity, important risk factors for cardiometabolic dysfunction, while maintaining HDL‐C concentrations.

Thursday, March 26, 2015

Left atrial appendage closure

This article in CCJM reviews the evidence, with a focus on the transcutaneous devices. The evidence from clinical trials is somewhat mixed and preliminary. As with any device, improvements in the technology far outpace clinical trials. The bottom line for now is that it is an emerging option for certain patients unable to take oral anticoagulants.

The electrocardiographic findings in massive or submassive PE: it's not just S1Q3T3!

The pattern and timing of T wave inversion can also be helpful as discussed here and here at the EMS 12 Lead blog.

As Henry J. L. (Barney) Marriott used to say, when you see T wave abnormality suggestive of simultaneous anterior AND inferior ischemia think acute cor pulmonale, as in massive or submassive PE.

ECMO: what the hospitalist needs to know

Why would a hospitalist need to know about ECMO? The applications are expanding rapidly. Hospitalists are increasingly likely to be involved in the care of patients who need the procedure and may be involved, at least indirectly, in determining a patient's candidacy. Here is a very helpful free full text review.

Arterial lines: evidence based or not?

In this large propensity-matched cohort analysis no mortality benefit was seen.

Wednesday, March 25, 2015

Early post resuscitation cardiac catheterization

---is associated with improved survival, overall and neurologically intact, in this meta-analysis. The analysis was based on low level data. There were no randomized trials. The data were not restricted to patients who met STEMI criteria although, as one would expect, “STEMI patients” were subjected to early invasive treatment more often than others. The analysis led the authors to conclude that early cardiac catheterization is reasonable in post arrest patients in whom a cardiac cause is even suspected, and that the decision should not be based solely on the presence or absence of ECG STEMI findings.

Autoimmune pancreatitis

Review here. It is now recognized that there are two types of AIP and only type I is associated with IgG-4.

Tuesday, March 24, 2015

Why public reporting is meaningless

Recently I've been working through some required learning modules for clinical documentation and coding. Most physicians know that the wording used in progress notes and discharge summaries can modify the DRG payment and greatly impact the hospital's reimbursement. What may be less well appreciated is that these little documentation tweaks can also impact severity adjustment which in turn affects the physician's rating in public reporting sites. I was recently reminded that with a little creative writing just changing a word here and there, the provider can radically impact how a patient encounter looks to outsiders. For example, the same patient could be portrayed as a stable medical patient on the ward, or, with a few little tweaks and the help of your clinical documentation specialist, a critically ill patient in the ICU. The language you use in your chart documentation makes all the difference in your public reporting profile regardless of how good a doctor you are. Physicians, particularly hospitalists, are encouraged to develop this skill because the hospital's livelihood depends on it. Enhancement of the doctor's public reporting profile is a side benefit and has nothing to with his or her skill or effectiveness as a clinician. A physician who is well versed in this creative chart documentation may even push the envelope of fraud but the regulating authorities will likely never know. Having observed these things over the last few years I've become increasingly skeptical of the value of public reporting, yet many of our hospitalist leaders who have a strong focus on health care policy continue to drink this Kool-Aid and serve it up to others.  

From experienced clinician to master clinician

Dr. Gurpreet Dhaliwal, known by his colleagues as Goop, is regarded as one of the master clinicians in the department of Internal Medicine at UCSF. If you've attended very many SHM conferences you've probably been bedazzled watching him discuss a mystery case in CPC fashion.

How do you get to be a master clinician? Are some people just born that way? Goop has pondered this question and decided it's a matter of attitude and motivation as much as anything else. It's the subject of a talk he gave, which I was fortunate enough to attend, at the Society of Hospital Medicine national meeting last spring. That same talk, given as a guest medical grand rounds speaker at the University of Washington, is available for viewing here.

Goop tries to be evidence based in his talk but encounters a problem: there has been next to no research on this question in clinical medicine. In attempting to work around the problem Goop has to look to non medical fields, in which there is a fair body of research on what makes an expert. But such research tends to be unconvincing, as comparison of the art and science of medicine with the mechanics of industry falls short time after time. Fortunately though Goop sprinkles in plenty of personal insights he has gained on his journey to becoming a master clinician. I'll unpack a few things here that rang true to me although I recommend everyone watch the video in its entirety at the link above.

It's a lot about attitude.
Complacency is the enemy. The slide appearing about six minutes into the talk reflects the typical career learning curve. Early on the curve is steep. Everything is new and it's a struggle. After a while, though, things get easier. As experience accumulates we become comfortable and the curve flattens. This, according to Goop, is a zone of complacency where professional stagnation and eventual decline may ensue. The key to staying out of this rut is to keep the curve steep but it takes deliberate effort. If you're comfortable in a particular content area make it harder by inventing new challenges and go after them. Curiosity and humility, the realization of how little you know, are important drivers.

Practice must be deliberate.
Passive practice, the kind we get from seeing a lot of patients, is an inefficient learning method. Deliberate practice might mean, for example, making it a point to carefully review as many electrocardiograms (or rashes or images, etc) as possible during a given month along with related material in textbooks or review articles.

Make the most of case reports.
Though relegated to “low impact” status in medical journals, case reports can be powerful learning tools when read with deliberate learning objectives (not just casually). Case records and clinical problem solving exercises in the New England Journal of Medicine are but two examples.

Is this the next version of MOC? It's a lot of work but there is a key difference. Unlike MOC this is self motivated and self directed. And it's a much more robust form of learning than that which is imposed by some outsider who knows nothing of your educational needs.


Deployment related lung disease---recent insights

Here is an update from Current Opinion in Pulmonary Medicine.

Background from previous posts on this topic can be found here.

Atrial fibrillation and silent cerebral infarction (SCI)

There is a two fold increase in the odds for SCI attributable to atrial fibrillation in this systematic review and meta-analysis.

Monday, March 23, 2015

Hypertensive emergencies and severe asymptomatic hypertension

This post from S.O.A.P. nicely covers true hypertensive emergencies and their distinction from severe asymptomatic hypertension.

D 10 versus D 50 for treatment of severe hypoglycemia

D 10 may be as good or better. Via Academic Life in Emergency Medicine.

A systematic review of four popular weight loss diets

Recent findings:
Background—We conducted a systematic review to examine the efficacy of the Atkins, South Beach, Weight Watchers (WW), and Zone diets...

Conclusions—Head-to-head RCTs, providing the most robust evidence available, demonstrated that Atkins, WW, and Zone achieved modest and similar long-term weight loss. Despite millions of dollars spent on popular commercial diets, data are conflicting and insufficient to identify one popular diet as being more beneficial than the others.

Saturday, March 21, 2015

Diagnosis takes a back seat under administrative pressures

A pithy little note over at DB's Medical Rants got me thinking. From the post:

Diagnosis generally dominates the first few admission days. We cannot really develop a good treatment plan until we solve the diagnostic dilemma.

I agree. But given typical lengths of stay of three or four days that means the majority time spent in the hospital should be devoted to just getting the right diagnosis for many patients. Worse, a significant number will leave the hospital without being correctly diagnosed at all.

But today's external pressures drive us in another direction, which is to force a diagnostic label on the patient too early. First the emergency physician is pressured to label the patient in order to convince the hospitalist to accept the patient for admission. Then the hospitalist has to assign a “principle problem.” If the problem statement is vague (such as a symptom), as is often appropriate, pressure comes from the coding and quality people to make the diagnosis more specific and get the patient on a care pathway. The performance incentives that follow are meaningless if the resulting diagnosis is incorrect.

Dr. Lawrence Weed, originator of the problem oriented medical record, appreciated this fact decades ago when he gave us this rule: in stating the patient's problem do not go beyond the level or resolution you have at the time. If that means listing the problem as “funny looking EKG” so state it until further data and expertise become available.

More tweaks proposed for the hospitalist model of care

The hospitalist model came into being with the hope that it would result in improved quality and cost efficiency. That hope did not withstand scientific scrutiny despite the persistent claims of some. While many hospitalists ascend a long and steep learning curve, thereby becoming quite skilled in the management of inpatients, that advantage may be outweighed by the discontinuity that is built into the system.

Concerns about this discontinuity prompted some leaders to propose modifications which would in effect dismantle the model. Some, for example, have suggested that hospitalists spend part of their time in the clinic. A few years ago AAFP promulgated guidelines calling for PCPs to collaborate with ER doctors before their patients are admitted to hospitalists, and to be involved in their patients' hospital stays. None of these ideas were widely adopted.

Now a Perspective piece in the New England Journal of Medicine proposes taking things a step further:

Under this voluntary system, PCPs would visit their hospitalized patients within 12 to 18 hours after admission to provide support and counseling to them and their families and consultation to the hospitalist team. The consultation would focus on the direction and scope of the patient's workup and care. The PCP would write a succinct consultation note, highlighting key elements of the patient's history (including pertinent family and psychosocial components), physical exam, and recent testing, and conclude with a prioritized differential diagnosis and recommendations for personalized inpatient evaluation and management. The hospitalist team would still retain full attending-physician responsibilities.

The initial consultation — contributing insights from an established doctor–patient relationship — would be designed to complement and help inform the hospitalist's admission workup and care plan, aiming to reduce hospitalist workload while increasing personalization of care. Subsequent to the admission consultative visit, the PCP would be available to meet with the patient, family, and hospitalist team on an as-needed basis, returning just before discharge to consult on the design of a coordinated posthospital program.

This means the PCP would round at least twice during the patient's hospital stay. Given a typical length of stay of about 4 days that means he or she would be rounding at least half the time. Although most hospitalists I know would be delighted to see the PCPs reaching inside the walls of hospitals this proposal would dismantle the hospitalist model as we now know it. It would take a radical payment shift to create enough incentive to bring something like this about and, despite the optimism in today's reform climate I don't see it happening any time soon.



Guidelines for intravascular catheter related infections

These guidelines from the IDSA were released in 2009. Though they may seem dated they are the most current guidelines form IDSA on the topic. No new version is expected anytime soon.

There are almost endless clinical scenarios (suspected versus established infection, type of organism, patient characteristics, type of catheter) and treatment options (duration and type of antibiotic, lock therapy, removal versus retention). The guidelines, accordingly, are quite complicated, a bit more than you could be expected to remember. This is a reference the hospitalist needs to have handy.

Weight loss drugs: risks versus benefits

Throughout their history weight loss drugs have taken off pounds but ultimately proved harmful. Here is a free full text review which traces the multiple generations of these agents and evaluates the latest offerings. Even these purportedly safer drugs have concerns and have yet to be adequately tested for long term cardiovascular outcomes.

Wednesday, March 11, 2015

Hemicraniectomy for catastrophic MCA stroke


From NEJM:

BACKGROUND:

Early decompressive hemicraniectomy reduces mortality without increasing the risk of very severe disability among patients 60 years of age or younger with complete or subtotal space-occupying middle-cerebral-artery infarction. Its benefit in older patients is uncertain.

METHODS:

We randomly assigned 112 patients 61 years of age or older (median, 70 years; range, 61 to 82) with malignant middle-cerebral-artery infarction to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy (the hemicraniectomy group); assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, which ranges from 0 [no symptoms] to 6 [death]) 6 months after randomization.

RESULTS:

Hemicraniectomy improved the primary outcome; the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, as compared with 18% in the control group (odds ratio, 2.91; 95% confidence interval, 1.06 to 7.49; P=0.04). This difference resulted from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0 to 2 (survival with no disability or slight disability); 7% of patients in the surgery group and 3% of patients in the control group had a score of 3 (moderate disability); 32% and 15%, respectively, had a score of 4 (moderately severe disability [requirement for assistance with most bodily needs]); and 28% and 13%, respectively, had a score of 5 (severe disability). Infections were more frequent in the hemicraniectomy group, and herniation was more frequent in the control group.

CONCLUSIONS:

Hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. The majority of survivors required assistance with most bodily needs.



Tuesday, March 10, 2015

Extracorporeal life support in severe ARDS


Despite recent advances and rapidly accumulating experience, high level evidence is lacking. Here is an update.

Monday, March 09, 2015

Time limited versus grandfathered board certified internists

This study compared the two groups along various performance metrics:

Main Outcomes and Measures Ten primary care performance measures: colorectal screening rates; diabetes with glycated hemoglobin (HbA1c level) less than 9.0%; diabetes with blood pressure less than 140/90 mm Hg; diabetes with low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL; hypertension with blood pressure less than 140/90 mm Hg; thiazide diuretics used in multidrug hypertensive regimen; atherosclerotic coronary artery disease and LDL-C level less than 100 mg/dL; post–myocardial infarction use of aspirin; post–myocardial infarction use of β-blockers; congestive heart failure (CHF) with use of angiotensin-converting enzyme (ACE) inhibitor.
Results After adjustment for practice site, panel size, years since certification, and clustering by physician, there were no differences in outcomes for patients cared for by internists with time-limited or time-unlimited certification for any performance measure...

These results must be viewed in terms of the limitations of using performance metrics as a surrogate.

Evidence summary on high risk PE


From a recent update:


Purpose of review: Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review.

Recent findings: The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results.


Sunday, March 08, 2015

Costs and outcomes for MOC-required versus MOC-grandfathered internists

Here's an interesting paper that recently appeared in JAMA:

Importance In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes.

Objective To measure associations between the original ABIM MOC requirement and outcomes of care....

One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control.

Main Outcomes and Measures Quality measures were ambulatory care–sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care...

Results Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, −1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of −$167 (95% CI, −$270.5 to −$63.5; P = .002; 2.5% of overall mean cost).

Conclusion and Relevance Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

My take on this very busy abstract is that requiring MOC was not associated with improved outcomes but was associated with a very modest cost reduction in this study.

Friday, March 06, 2015

Chest CT findings in acute pericarditis

From a recent study:


Material and Methods: Using the electronic medical record, we retrospectively identified 46 cases of acute pericarditis and 46 control patients with pericardial effusions due to volume overload, all of whom underwent CT examination. Cases were reviewed by two blinded academic thoracic radiologists.
Results: The majority, 67%, of the pericarditis cases were evaluated with PE-protocol CTs. Pericardial thickening/enhancement was the most accurate single parameter for pericarditis, with sensitivity of 54–59% and specificity of 91–96%.
Conclusion: CT findings, while not sensitive for pericarditis, are diagnostic, with few false-positives.

Via Hospital Medicine Virtual Journal Club.

Thursday, March 05, 2015

Broken ribs and other injuries from CPR---how often?

Here’s a study of patients undergoing CT scanning post resuscitation, both successful and unsuccessful:

During the study period, 309 patients who suffered out-of hospital cardiac arrest were transported to our emergency room and received CPR; 223 were enrolled in the study.
The CT images showed that 156 patients (70.0%) had rib fractures, and 18 patients (8.1%) had sternal fractures. Rib fractures were associated with older age (78.0 years vs. 66.0 years, p less than 0.01), longer duration of CPR (41 min vs. 33 min, p less than 0.01), and lower rate of ROSC (26.3% vs. 55.3%, p less than 0.01). All sternal fractures occurred with rib fractures and were associated with a greater number of rib fractures, higher age, and a lower rate of ROSC than rib fractures only cases. Bilateral pneumothorax was observed in two patients with rib fractures.

Via Hospital Medicine Virtual Journal Club.

Wednesday, March 04, 2015

Bedside diagnosis of dysphagia---is it adequate?

From a systematic review:

We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

The problem with this paper is the choice of gold standard. Bedside evaluation will not pick up as many abnormalities as will video fluoroscopy, but how many positive video studies are really clinically significant?

Via Hospital Medicine Virtual Journal Club.

Monday, March 02, 2015

Systematic review on treatment of calcium blocker overdose

Free full text here.

Academic Life in Emergency Medicine summarizes the review:

A few findings from the systematic review:

The majority of literature on calcium channel blocker overdose management is heterogenous, biased, and low-quality evidence.

Interventions with the strongest evidence are high-dose insulin and extracorporeal life support.

Interventions with less evidence, but still possibly beneficial, include calcium, dopamine, norepinephrine, 4-aminopyridine (where available), and lipid emulsion therapy.

Stay tuned for the international guideline coming out soon. One treatment recommendation from the new guideline, reported at the 8th European Congress on Emergency Medicine September 2014, is not to use glucagon.

Sunday, March 01, 2015

Beta blockers in heart failure with preserved ejection fraction

From a recent paper in JAMA:

Objective To test the hypothesis that β-blockers are associated with reduced all-cause mortality in HFPEF.

Design Propensity score–matched cohort study using the Swedish Heart Failure Registry. Propensity scores for β-blocker use were derived from 52 baseline clinical and socioeconomic variables.

Setting Nationwide registry of 67 hospitals with inpatient and outpatient units and 95 outpatient primary care clinics in Sweden...

Participants From a consecutive sample of 41 976 patients, 19 083 patients with HFPEF (mean [SD] age, 76 [12] years; 46% women). Of these, 8244 were matched 2:1 based on age and propensity score for β-blocker use, yielding 5496 treated and 2748 untreated patients with HFPEF. Also we conducted a positive-control consistency analysis involving 22 893 patients with HFREF, of whom 6081 were matched yielding 4054 treated and 2027 untreated patients.

Exposures β-Blockers prescribed at discharge from the hospital or during an outpatient visit...

In the matched HFPEF cohort, 1-year survival was 80% vs 79% for treated vs untreated patients, and 5-year survival was 45% vs 42%, with 2279 (41%) vs 1244 (45%) total deaths and 177 vs 191 deaths per 1000 patient-years (hazard ratio [HR], 0.93; 95% CI, 0.86-0.996; P = .04). β-Blockers were not associated with reduced combined mortality or heart failure hospitalizations: 3368 (61%) vs 1753 (64%) total for first events, with 371 vs 378 first events per 1000 patient-years (HR, 0.98; 95% CI, 0.92-1.04; P = .46)...

Conclusions and Relevance In patients with HFPEF, use of β-blockers was associated with lower all-cause mortality but not with combined all-cause mortality or heart failure hospitalization. β-Blockers in HFPEF should be examined in a large randomized clinical trial.