MRCGP exam update: Beta-blockers in heart failure

Current situation
  • Heart failure (HF) is a common but poorly managed condition.
  • More patients survive an MI today than before, and up to half of these patients may later develop HF.

What is the evidence?

  • Large trials, for example the Cardiac Insufficiency Bisoprolol Trial II, the Carvedilol Prospective Randomised Cumulative Survival Study (COPERNICUS) and the Metoprolol Randomised Intervention Trial in Congestive Heart Failure, have shown that beta-blocker treatment with bisoprolol, carvedilol and metoprolol reduces mortality in advanced HF patients.
  • An overview of randomised trials found that beta-blockers were well tolerated by patients (Arch Intern Med 2004; 164: 1,389). In the trials reviewed, more patients were withdrawn from treatment with a placebo than with a beta-blocker.
  • The results of one study suggest that greater heart rate reduction with beta-blockers is associated with better outcomes for patients (Congest Heart Fail 2006; 12: 206).
  • A recent study showed that beta-blocker treatment before and during hospitalisation for HF is associated with improved outcomes (J Am Coll Cardiol 2006; 47: 2,462).
  • One study showed that GPs are prescribing beta-blockers and ACE inhibitors for heart failure at lower doses than is recommended (Eur Heart J 2005; 26: 2, 706).

Implications for practice

  • Temporary exacerbation of  HF symptoms may occur in between 20 and 30 per cent of patients after starting beta-blockers, necessitating increased diuretic therapy.
  • Most patients in the UK receive bisoprolol or carvedilol because metoprolol is not licensed to treat HF.
  • Starting HF treatment with a beta-blocker appears to be as safe and effective as starting with an ACE inhibitor, according to the results of the Cardiac Insufficiency Bisoprolol Study (Circulation 2005; 112: 2,426-35).

Available guidelines

  • The NICE guideline states that beta-blockers for HF should be initiated regardless of whether or not the patient's symptoms persist after standard treatment.

Useful websites - NICE. - British Heart Foundation.

Dr Louise Newson is a GP in the West Midlands and author of ‘Hot Topics for MRCGP and General Practitioners', PasTest 2006


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