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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. About Journal Watch • Journal Watch helps physicians and allied heath professionals save time and stay informed by providing brief, clearly written, clinically focused perspectives on the medical developments that affect practice. • Journal Watch is an independent, trustworthy source, from the publishers of the New England Journal of Medicine. • These slides were derived from Journal Watch Cardiology. • The best way to stay informed with Journal Watch, is through our alerts. To sign up, visit the My Alerts page. Copyright © 2009. Massachusetts Medical Society. All rights reserved.