MRCGP Exam Update - Heart failure and beta-blockers

Current situation

- Heart failure is a common condition.

- More patients are surviving an MI today than ever before, and up to half of these patients may later develop heart failure.

- Despite strong evidence that beta-blockers increase the length and quality of life in people with heart failure, only 37 per cent of eligible patients are receiving a beta-blocker (Eur Heart J 2003; 24: 464).

What is the evidence?

- Recent large, randomised, controlled trials, CIBIS-II (Cardiac Insufficiency Bisoprolol Trial II), COPERNICUS (Carvedilol Prospective Randomised Cumulative Survival Study) and MERIT-HF (Metoprolol Randomised Intervention Trial in Congestive Heart Failure) have shown that beta-blocker treatment with bisoprolol, carvedilol and metoprolol XL, respectively, reduce mortality in advanced heart failure patients.

- An overview of randomised trials found that beta-blockers are generally well tolerated by patients (Arch Intern Med 2004; 164: 1,389). Beta-blocker therapy was associated with hypotension, dizziness and bradycardia. However, it was associated with reductions in mortality, heart-failure associated hospitalisations and worsening heart failure. It is interesting that in the trials reviewed, more patients were withdrawn from treatment with a placebo than with a beta-blocker.

- A comprehensive study has been published since the NICE guidelines - COMET (Carvedilol or Metoprolol European Trial).

COMET compared the effects of carvedilol and metoprolol tartrate in patients with moderate-to-severe heart failure (Lancet 2003; 362: 7).

It is one of the longest and largest beta-blocker studies conducted in HF.

The results showed a significant survival benefit of 17 per cent in patients treated with carvedilol compared to metoprolol.

- COMET also showed that carvedilol was associated with a 67 per cent reduction in risk of deaths due to stroke and a 22 per cent reduction in new-onset diabetes.

Primary care implications

- The NICE guideline makes it clear that beta-blockers licensed for heart failure should be initiated regardless of whether or not the patient's symptoms persist after standard treatment with diuretics and ACE inhibitors.

- Temporary exacerbation of symptoms may occur in 20-30 per cent of patients after starting beta-blockers.

- Most UK patients receive bisoprolol or carvedilol.

- Beta blockers are effective as starting with an ACE inhibitor, according to the results of the CIBIS (Cardiac Insufficiency Bisoprolol Study) (Circulation 2005; 112: 2,426-35).

USEFUL WEBSITES

www.nice.org.uk - NICE.

www.bhf.org.uk - British Heart Foundation.

- Dr Louise Newson is a GP in the West Midlands and author of 'Hot topics for MRCGP and General Practitioners', PasTest 2004

KEY POINTS

- Many heart failure patients are not prescribed beta-blockers.

- Beta-blockers reduce mortality.

- Beta-blockers are better tolerated than believed.

- NICE guidelines advocate use of beta-blockers.

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