Dallas, TX - Strengthening the evidence base for what must be among the least invasive of interventions, a randomized trial suggests that a simple reminder attached to the echocardiography reports of patients with reduced LV systolic function can increase the likelihood they will be prescribed beta blockers [1].

The strategy, which can be implemented in just about any provider setting, raised beta-blocker use by about 12% in the study of more than a thousand patients, a fairly small margin but a solidly significant difference. "It's low impact, but very low cost, so overall it should be very cost effective," lead author Dr Paul A Heidenreich (VA Palo Alto Health Care System, CA) told heartwire. It may also play a role in getting the word on new treatment guidelines from print to the patient-care level.

In the study, 1271 patients with an LVEF <45% were randomized to have or not have a clinical reminder attached to their echocardiography report. The reminder said, "Note: Patients with reduced left ventricular ejection fraction have a survival benefit with beta blockers (initial dose: carvedilol 3.125 mg bid or metoprolol succinate 12.5 mg bid)" and recommended cardiology follow-up for patients with symptoms that put them in NYHA class 3 or 4. The two beta blockers were specified because they were known to improve survival and were readily available in the study's Veterans Affairs healthcare system, according to the authors.

On the other hand, the primary end point tracked the use of any beta blocker so as to include patients who may have entered the study on such drugs other than carvedilol or metoprolol and were allowed to stay on them, according to Heidenreich. When the study was designed, he said, it seemed more important to promote any beta-blocker therapy than restrict patients to the ones specified in the reminder; a secondary end point dealt with those.

The significant difference in postecho beta-blocker use persisted after exclusion of the 51% of patients who had an active prescription for a beta blocker at the time of randomization; the usage rates were 56% and 44% for those getting and not getting reminders, respectively (p=0.003).

Significant independent predictors of beta-blocker use included randomization to a clinical reminder, history of ischemic heart disease, prior statin therapy, and prior ACE-inhibitor or angiotensin-receptor-blocker use. Older age and a history of chronic obstructive pulmonary disease were independently associated with beta-blocker nonuse.

An overall increase in beta-blocker prescriptions—from about 30% of patients to about 50%—was observed over the course of the study, which started soon after publication of relevant guidelines, Heidenreich observed; patients were randomized from 2001 to 2005. Heidenreich said today, after the current study, beta-blocker use for patients like those who had been randomized is up to about 80% at his center.

"Although the reminder may have contributed to provider education, we feel it is more likely that clinicians became increasingly comfortable with prescribing beta blockers for multiple reasons, including colleague recommendations and guideline publication," Heidenreich and his coauthors write. "If the latter is correct, reminders will be most beneficial early in the dissemination of a new guideline and may not be effective indefinitely."

The group continues, "The implications extend beyond echocardiography to other cardiovascular and noncardiovascular reports. Electrocardiography reports may be used to distribute reminders for acute or post-myocardial-infarction care, and clinical laboratory test results may include suggestions for treatment."

Of note, the reminders failed to influence at least one measure of clinical outcomes: one-year survival free from heart-failure hospitalization.