Download July 15, 2009

Published in Journal Watch Cardiology
July 15, 2009
Beta-Blockade for Heart Failure: What to Aim For?
A meta-analysis suggests that improvements in mortality with beta-blockers are
more strongly associated with the heart rate achieved than with dose.
Summary and Comment by Frederick A. Masoudi, MD, MSPH
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
Covering
• McAlister FA et al. Meta-analysis: β-blocker dose, heart rate
reduction, and death in patients with heart failure. Ann Intern Med
2009 Jun 2; 150:784.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
Background
• Practice guidelines for treatment of systolic dysfunction strongly
recommend titrating beta-blockers to doses used in published
randomized trials.
• Achieving this goal is often challenging in practice, because the
adverse effects of beta-blockade are largely dose-related.
• To explore whether the benefits of beta-blockade for heart failure
relates to the reduction in heart rate, even at lower-than-target
doses, investigators conducted a meta-analysis of 23 randomized
trials of beta-blockers in patients with heart failure.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
The Research
• All-cause mortality was reported in all trials, and virtually all patients
had systolic dysfunction (96%) and were receiving ACE inhibitors
(93%).
• In four trials, beta-blockade conferred a significant survival benefit;
in all 23 trials, the pooled mortality risk ratio was 0.76.
• The benefits of beta-blockers had a linear correlation with the
reduction in resting heart rate: Relative mortality risk was 18% lower
for every 5 beat-per-minute reduction in heart rate.
• In contrast, no clear association was found between beta-blocker
dose and mortality.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
Comment
• This intriguing analysis of beta-blocker therapy for heart failure
suggests — at least in the aggregate — that reductions in heart rate
are more important indicators of therapeutic benefit than the
attainment of target doses.
• However, it would be premature to ignore guideline
recommendations for beta-blocker titration and use heart rate as a
primary measure of beta-blocker effectiveness.
• Patient-level analyses are needed to address the question of how
best to set individual goals for beta-blocker therapy.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
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Copyright © 2009. Massachusetts Medical Society. All rights reserved.