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Non-withdrawal of beta blockers in acute decompensated chronic and de novo heart failure with reduced ejection fraction in a prospective multicentre study of patients with acute heart failure in the Middle East
  1. Charbel Abi Khalil1,2,3,
  2. Kadhim Sulaiman4,
  3. Ziyad Mahfoud5,
  4. Rajvir Singh3,
  5. Nidal Asaad3,
  6. Khalid F AlHabib6,
  7. Alawi Alsheikh-Ali7,
  8. Mohammed Al-Jarallah8,
  9. Bassam Bulbanat9,
  10. Wael AlMahmeed10,
  11. Mustafa Ridha11,
  12. Nooshin Bazargani12,
  13. Haitham Amin13,
  14. Ahmed Al-Motarreb14,
  15. Husam Al Faleh6,
  16. Abdelfatah Elasfar15,
  17. Prashanth Panduranga4,
  18. Jassim Al Suwaidi3
  19. on behalf of the GULF-CARE group
  1. 1 Department of Medicine, Weill Cornell Medicine, Doha, Qatar
  2. 2 Department of Genetic Medicine, Weill Cornell Medicine, Doha, Qatar
  3. 3 Adult Cardiology Heart Hospital, Hamad Medical Corporation, Doha, Qatar
  4. 4 National Heart Center, Royal Hospital, Muscat, Oman
  5. 5 Division of Global and Public Health, Weill Cornell Medicine, Doha, Qatar
  6. 6 Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
  7. 7 College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
  8. 8 Department of Cardiology, Sabah Al-Ahmed Cardiac Center, Kuwait, Kuwait
  9. 9 Department of Medicine, Al-Amiri Hospital, Kuwait, Kuwait
  10. 10 Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, UAE
  11. 11 Department of Cardiology, Adan Hospital, Kuwait, Kuwait
  12. 12 Department of Cardiology, Dubai hospital, Dubai, UAE
  13. 13 Department of Cardiology, Mohammed Bin Khalifa Cardiac Center, Manamah, Bahrain
  14. 14 Department of cardiology, Faculty of Medicine, Sana’a University, Sana, Yemen
  15. 15 Department of cardiology, Tanta University, Tanta, Egypt
  1. Correspondence to Dr. Charbel Abi Khalil; cha2022{at}


Objectives Beta blockers reduce mortality in heart failure (HF). However, it is not clear whether they should be temporarily withdrawn during acute HF.

Design Analysis of prospectively collected data.

Setting The Gulf aCute heArt failuRe rEgistry is a prospective multicentre study of patients hospitalised with acute HF in seven Middle Eastern countries.

Participants 5005 patients with acute HF.

Outcome measures We studied the effect of beta blockers non-withdrawal on intrahospital, 3-month and 12-month mortality and rehospitalisation for HF in patients with acute decompensated chronic heart failure (ADCHF) and acute de novo heart failure (ADNHF) and a left ventricular ejection fraction (LVEF) <40%.

Results 44.1% of patients were already on beta blockers on inclusion. Among those, 57.8% had an LVEF <40%. Further, 79.9% were diagnosed with ADCHF and 20.4% with ADNHF. Mean age was 61 (SD 13.9) in the ADCHF group and 59.8 (SD 13.8) in the ADNHF group. Intrahospital mortality was lower in patients whose beta blocker therapy was not withdrawn in both the ADCHF and ADNHF groups. This protective effect persisted after multivariate analysis (OR 0.05, 95% CI 0.022 to 0.112; OR 0.018, 95% CI 0.003 to 0.122, respectively, p<0.001 for both) and propensity score matching even after correcting for variables that remained significant in the new model (OR 0.084, 95% CI 0.015 to 0.468, p=0.005; OR 0.047, 95% CI 0.013 to 0.169, p<0.001, respectively). At 3 months, mortality was still lower only in patients with ADCHF in whom beta blockers were maintained during initial hospitalisation. However, the benefit was lost after correcting for confounding factors. Interestingly, rehospitalisation for HF and length of hospital stay were unaffected by beta blockers discontinuation in all patients.

Conclusion In summary, non-withdrawal of beta blockers in acute decompensated chronic and de novo heart failure with reduced ejection fraction is associated with lower intrahospital mortality but does not influence 3-month and 12-month mortality, rehospitalisation for heart failure,and the length of hospital stay.

Trial registration number NCT01467973; Post-results.

  • heart failure
  • adult cardiology
  • cardiac epidemiology

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  • Contributors KS, KFA, NA, AA-A, MA-J, BB, WA, MR, NB, HA, AA-M, HAF, AE, PP and JAS were involved in the design of the Gulf CARE registry and patient enrolment and ensuring quality control of the study. CAK designed the analysis and wrote the manuscript. ZM and RS carried out the statistical analyses. All authors approved the final version of the manuscript.

  • Funding Gulf CARE is an investigator-initiated study conducted under the auspices of the Gulf Heart Association and funded by Servier, Paris, France and (for centres in Saudi Arabia) by the Saudi HeartAssociation. Dr Abi Khalil’s lab is funded by the Biomedical Research Program (BMRP) at Weill Cornell Medicine-Qatar, a programme funded by Qatar Foundation, and by two grants from the Qatar National Research Funds under its National Priorities Research Program award numbers (NPRP 7 - 701 - 3 – 192 and NPRP 9-169-3-024). Dr Al-Habib’s lab is funded by the Saudi Heart Association and The Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number: RG -14360-013).

  • Disclaimer The funders did not have a role in the study’s concept, analysis and writing of the manuscript.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The registry protocol was approved by each participating centre’s institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data include human data. To protect participant privacy, the data are available on request from the corresponding author.

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