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The health care providers should always understand the intricacies of the problem related to the patient before choosing the stage-appropriate treatment for heart failure.

Background: Despite recent advances in the treatment and prevention of cardiovascular disease, a treatment gap for secondary prevention medications still exists. Objective: To develop and implement a program ensuring appropriate prescription of aspirin, statins, [beta]-blockers, angiotensin-converting enzyme inhibitors, and warfarin at hospital discharge. Design: A nonrandomized before-after study comparing patients hospitalized before (1996-1998) and after (1999-2002) implementation of a discharge medication program (DMP). Patients were followed for up to 1 year. Setting: The 10 largest hospitals in the Utah-based Intermountain Health Care system. Patients: In the pre-DMP and DMP time periods, 26 000 and 31 465 patients, respectively, were admitted to cardiovascular services (n = 57 465). Measurements: Prescription of indicated medications at hospital discharge; postdischarge death or readmission. Results: By 1 year, the rate of prescription of each medication increased significantly to more than 90% (P < 0.001); this rate was sustained. At 1 year, unadjusted absolute event rates for readmission and death, respectively, were 210 per 1000 person-years and 96 per 1000 person-years before DMP implementation and 191 per 1000 person-years and 70 per 1000 person-years afterward. Relative risk for death and readmission at 30 days decreased after DMP implementation; hazard ratios (HRs) for death and readmission were 0.81 (95% CI, 0.73 to 0.89) and 0.92 (CI, 0.87 to 0.99) (P < 0.001 and P = 0.017, respectively). At 1 year, risk for death continued to decrease (hazard ratio, 0.79 [CI, 0.75 to 0.84]; P< 0.001) while risk for readmission stabilized (hazard ratio, 0.94 [CI, 0.90 to 0.98]; P = 0.002), probably because survivors had more opportunities to be readmitted. Limitations: The study design was observational and nonrandomized, and the authors could not control for potential con-founders or determine the extent to which secular trends accounted for the observed improvements. Conclusions: A relatively simple quality improvement program aimed at enhancing the prescription of appropriate discharge medications among cardiovascular patients is feasible and can be sustained within an integrated multihospital system. Such a program may be associated with improvements in cardiovascular readmission rates and mortality.

PURPOSE: Bucindolol is a potent nonselective [Beta]-blocking agent with vasodilatory properties. In this study, we evaluated the effects of long-term bucindolol therapy in the treatment of heart failure from idiopathic dilated cardiomyopathy. PATIENTS AND METHODS: Patients were eligible for enrollment if they had symptomatic heart failure, idiopathic dilated cardiomyopathy, and left ventricular ejection fraction less than 0.40. All patients received an initial test dose of 12.5 mg bucindolol orally every 12 hours for two or three doses. Patients tolerating the test dose were randomLy assigned (double-blind) to receive bucindolol or placebo in a 3:2 ratio. Study medication was begun at a dose of 12.5 mg orally every 12 hours and gradually increased over a 1-month period until either a maximum tolerated dose or a target dose of 100 mg every 12 hours was reached. Study medication was then continued for an additional 2 months. RESULTS: A total of 24 patients were enrolled into the study. Twenty-three patients tolerated bucindolol test challenge; 14 were randomized to receive bucindolol, and nine were randomLy assigned to receive placebo. The placebo group (age 56 [+ or -] 2 years) was significantly older than the bucindolol group (46 [+ or -] 3 years), but by aU other clinical and hemodynamic parameters the two groups were comparable. Twenty-two of 23 patients completed the study. Patients treated with bucindolol had significant improvements in clinical heart failure symptoms and in resting hemodynamic function, including an increase of left ventricular ejection fraction (0.26 [+ or -] 0.02 to 0.35 [+ or -] 0.09, p = 0.003), cardiac index (2.2 [+ or -] 0.1 to 2.5 [+ or -] 0.4 L/minute/m[.sup.2], p = 0.014), and left ventricular stroke work index (25 [+ or -] 3 to 35 [+ or -] 7 g.M/M[.sup.2], p = 0.002) and a decrease in pulmonary artery wedge pressure (17 [+ or -] 3 to 10 [+ or -] 5 mm Hg, p = 0.005) and heart rate (86 [+ or -] 3 to 75 [+ or -] 9 beats/minute, p = 0.012). Patients treated with bucindolol also had a significant increase in exercise left ventricular ejection fraction (0.26 [+ or -] 0.03 to 0.32 [+ or -] 0.14, p = 0.015) and reduction in questionnaire-measured symptoms (p = 0.007) and New York Heart Association functional class (p CONCLUSION: Bucindolol is well tolerated in patients with idiopathic dilated cardiomyopathy and congestive heart failure, and therapy for 3 months is associated with improved resting cardiac function, improved heart failure symptoms, and a reduction in venous norepinephrine concentration., Bucindolol is a beta-blocking drug that is capable of dilating blood vessels. The effectiveness of bucindolol in treating congestive heart failure with idiopathic dilated cardiomyopathy was assessed in 14 patients. A comparison group of nine patients was given a placebo, or inert substance. Bucindolol improved symptoms of heart failure and circulatory function, and increased the left ventricular ejection fraction, which is a measure of the contractility of the heart. The beta-blocking agent improved other measures of heart function including cardiac index, left ventricular stroke work index, pulmonary wedge pressure, and heart rate. Patients receiving bucindolol also had increased left ventricular ejection fraction during exercise and improvement in symptoms, as indicated on a questionnaire. However, the length of time patients could exercise on a treadmill and the consumption of oxygen did not change after bucindolol therapy. Patients receiving a placebo did not experience any changes in heart function or symptoms of heart failure at rest or during exercise. Norepinephrine, a natural substance, is released by nerves in excessive amounts during heart failure to maintain heart contraction. The blood levels of norepinephrine were decreased in patients taking bucindolol, but not in patients given a placebo. The results show that bucindolol is well tolerated by patients with heart failure, and treatment with this beta-blocking agent for three months resulted in improvements in heart function, symptoms of heart failure, and norepinephrine levels. (Consumer Summary produced by Reliance Medical Information, Inc.)