Beta-Blocker Continuation Linked to More Heart Transplants
Key Takeaways
- In a retrospective single-center cohort from São Paulo, Brazil, 53 adult patients actively listed for heart transplantation had already completed at least 30 consecutive days of concomitant oral beta-blocker therapy and continuous intravenous dobutamine before study entry.
- After inverse probability of treatment weighting, beta-blocker continuation after the index date was associated with a higher cumulative incidence of heart transplantation at 270 days or later.
- After weighting, beta-blocker continuation was also associated with a lower cumulative incidence of pre-transplant death at 270 days or later. The authors described the signal as hypothesis-generating because suspension occurred during hemodynamic deterioration and residual confounding by indication likely remained.
In the competing-risk analysis, investigators at Instituto Dante Pazzanese de Cardiologia in São Paulo, Brazil, retrospectively examined patients treated between January 2020 and December 2023; eligibility required completion of the 30-day concomitant-treatment period before the index date, and 35 patients were maintained on beta-blockers while 18 had therapy suspended. Follow-up ended with transplantation, death, or censoring. Overall, 29 patients underwent transplantation, 16 died before transplantation, and 8 were censored, and the authors used competing-risk methods because death before transplantation precludes the transplant outcome itself.
After inverse probability of treatment weighting, cumulative incidence at 270 days or later was 61.1% versus 14.3% for transplantation and 13.3% versus 68.7% for pre-transplant death with continuation versus suspension. Fine-Gray modeling showed a transplantation sHR of 8.79 (95% bootstrap CI 2.66–54.31) and a pre-transplant-death sHR of 0.077 (95% bootstrap CI 0.014–0.192). All four prespecified sensitivity analyses were directionally consistent, although the doubly robust transplantation estimate was not reported because only four transplants occurred in the suspended group. After weighting, 9 of 11 variables were below |SMD| 0.10, but LVEF remained 0.28 and NT-proBNP 0.47, both in the direction of greater disease severity in the suspended group, so beta-blocker continuation may mark relative hemodynamic stability in this cohort rather than establish a treatment effect.
Clinician Questions
Which heart transplant candidates were included in the beta-blocker and dobutamine cohort?
The cohort included adults aged 18 years or older who were actively listed for heart transplantation, were hospitalized at Instituto Dante Pazzanese de Cardiologia in São Paulo, Brazil, and had completed at least 30 consecutive days of concomitant oral beta-blocker therapy and continuous intravenous dobutamine before the index date.
How did beta-blocker continuation compare with suspension for transplantation and pre-transplant death after 270 days?
Among transplant-listed adults already tolerating prolonged concomitant beta-blocker and continuous intravenous dobutamine therapy, beta-blocker continuation was associated with heart transplantation in 61.1% versus 14.3% and pre-transplant death in 13.3% versus 68.7% at 270 days or later.
What cautions limit interpretation of beta-blocker continuation during prolonged dobutamine bridging to transplant?
Interpretation is limited because the analysis was a retrospective single-center cohort, beta-blocker suspension occurred during cardiogenic or septic shock, residual imbalance in LVEF and NT-proBNP remained after weighting, only four transplants occurred in the suspended group, and the investigators described the findings as hypothesis-generating prognostic associations rather than causal evidence.