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[The use of beta blockers in heart failure: clinical studies]
1Divisione di Cardiologia, Centro Medico di Montescano, Fondazione Salvatore Maugeri, IRCCS. fcobelli@fsm.it
Insights
Beta-blockers significantly reduce mortality and hospital readmissions in chronic heart failure (CHF) patients. These findings confirm the benefits of beta-blocker therapy in improving survival rates for eligible CHF populations.
Area of Science:
- Cardiology and Cardiovascular Diseases
- Pharmacology and Therapeutics
Context:
- Despite advances with angiotensin-converting enzyme (ACE) inhibitors, chronic heart failure (CHF) mortality remains high.
- Previous research suggested beta-blockers could improve hemodynamics and survival in CHF patients.
Purpose:
- To evaluate the efficacy of beta-blocker therapy in reducing mortality and hospital readmissions in patients with chronic heart failure (CHF).
- To synthesize findings from six major randomized, placebo-controlled trials involving approximately 9000 CHF patients.
Summary:
- Six trials demonstrated that adding beta-blockers (metoprolol, bisoprolol, carvedilol) to standard CHF treatment significantly reduced total mortality by 33.3%, cardiac death by 34.2%, sudden death by 37.7%, and heart failure worsening by 41.7%.
- Beta-blocker treatment also led to a 31.7% reduction in all-cause hospital readmissions and a 26% reduction in the combined endpoint of mortality and readmission.
- While ventricular function improved, functional capacity did not show significant enhancement.
Impact:
- Provides convincing evidence for the favorable effects of beta-blockade in reducing death and hospital readmission risk for specific CHF patient groups (dilated cardiomyopathy, systolic dysfunction, <70 years, NYHA class II-III).
- Highlights the need for further research into the effects of beta-blockers in CHF patients with normal ejection fraction, older age (>65-70 years), NYHA class IV, or significant comorbidities.
Abstract:
Although inhibitors of angiotensin-converting enzyme (ACE) have improved the treatment of chronic heart failure (CHF), mortality related to this disorder remains unacceptably high. Results from studies started more than 25 years ago in Sweden suggested that long-term therapy with beta-blockers could improve hemodynamics and increase survival in patients with CHF; this hypothesis is confirmed by the results of six double-blind, randomized, placebo-controlled trials (MDC, CIBIS, ANZ, US Carvedilol Study, CIBIS II and MERIT-HF) who enrolled about 9000 patients with CHF. In these trials beta-blockers (metoprolol, bisoprolol or carvedilol) where added to the stable usual treatment of each patient (ACE-inhibitors, diuretics, digoxin). Baseline characteristics of patients enrolled into the beta-blocker or placebo arm were similar in all these studies. Specifically the mean patient's age was < 60 years, with a mean left ventricular ejection fraction of 25-26%, 30% of enrolled patients were in NYHA functional class II and 60% in NYHA functional class III, CHF was due to ischemic heart disease in about 60% of patients. The average follow-up for all the trials was 14.5 +/- 5.6 months. On the whole in patients on beta-blocker treatment there is a 33.3% reduction in total mortality rate, a 34.2% reduction in cardiac death rate, a 37.7% reduction in sudden death rate, and a 41.7% reduction in worsening heart failure mortality rate. Moreover, in beta-blocker patients there is a 31.7% reduction in all-cause readmissions to hospital and a 26% reduction in the combined end point (total mortality and hospital readmission). Beta-blockers improved ventricular function but there was no significant improvement in functional capacity. In conclusion, the results of the six trials considered indicate that there is convincing evidence supporting a favorable effect of beta-blockade on the risk of death and readmission to hospital in patients with dilated cardiomyopathy with systolic dysfunction, aged < 70 years, in NYHA functional class II-III. The effects of these drugs in CHF patients a) with normal left ventricular ejection fraction, b) aged > 65-70 years, c) in NYHA functional class IV, and d) with comorbilities such as obstructive lung disease, diabetes, peripheral arterial diseases, require additional study.