Population-based analysis of class effect of β blockers in heart failure

The long-term use of β blockers has been shown to improve the outcomes of patients with heart failure (HF). However, it is still disputed whether this is a class effect, and, specifically, whether carvedilol or bisoprolol are superior to metoprolol. The present study was a comparative effectiveness study of β blockers for patients with HF in a population-based setting. We conducted an observational cohort study using the Quebec administrative databases to identify patients with HF who were prescribed a β blocker after the diagnosis of HF. We used descriptive statistics to characterize the patients by the type of β blocker prescribed at discharge. The unadjusted mortality for users of each β blocker was calculated using Kaplan-Meier curves and compared using the log-rank test. To account for differences in follow-up and to control for differences among patient characteristics, a multivariate Cox proportional hazards model was used to compare the mortality. Of the 26,787 patients with HF, with a median follow-up of 1.8 years per patient, the crude incidence of death was 47% with metoprolol, 40% with atenolol, 41% with carvedilol, 36% with bisoprolol, and 43% with acebutolol. After controlling for several different covariates, we found that carvedilol (hazard ratio [HR] 1.04, 95% confidence interval [CI] 0.97 to 1.12, p = 0.22) and bisoprolol (HR 0.96, 95% CI 0.91 to 1.01, p = 0.16) were not superior to metoprolol in improving survival. Atenolol (HR 0.82, 95% CI 0.77 to 0.87, p <0.0001) and acebutolol (HR 0.86, 95% CI 0.78 to 0.95, p = 0.004) were superior to metoprolol. In conclusion, we did not find evidence of a class effect for β blockers in patients with HF.