Controversies in the Use of Beta Blockers in Heart Failure
Controversies in the Use of Beta Blockers in Heart Failure
Recent evidence from randomized controlled trials has provided compelling evidence to support the use of β blockers in most patients with heart failure due to systolic dysfunction. There is little disagreement about the mortality benefit provided by adding β blockers to standard therapy, which may include angiotensin-converting enzyme inhibitors, diuretics, and sometimes digoxin. A few areas are still controversial. The authors review the available literature encompassing four of those controversial areas: 1) the comparability among β blockers; 2) the utility of β blockers among patients with New York Heart Association class I and class IV heart failure symptoms; 3) the impact of race on the effectiveness of β blockers; and 4) the safety and efficacy of β blockers among patients on concomitant therapy with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or spironolactone.
Recent trials have provided compelling evidence to support the use of β blockers in heart failure (HF) due to systolic dysfunction. Current, major published guidelines support this concept and offer guidance on how to administer them in appropriate patients. Still, there are controversies.
The majority of patients with HF may derive long-term benefit from the addition of β blockers to background therapy, which may include an-giotensin-converting enzyme (ACE) inhibitors, loop diuretics, and digoxin. Only one comparative trial between β blockers in heart failure has been completed. This trial did not resolve the issue of comparability. Little clinical data exists among patients with New York Heart Association (NYHA) class I symptoms and some controversy remains over the appropriateness of routine administration to patients with NYHA class IV symptoms. Additionally, retrospective analyses of prior HF trials and one recently completed β -blocker trial have raised the specter of racial differences in the response of HF patients to pharmacologic therapy. Finally, there also remains uncertainty about how β blockers may interact with other medications. Evidence for the efficacy of β blockers was being gathered at the same time that spironolactone was being evaluated for its use in HF in the Randomized Aldactone Evaluation Study (RALES). As a result, none of the β -blocker trials were conducted with spironolactone as part of background therapy and only 10% of the RALES population was on β blockers. The recently released Valsartan Heart Failure Trial (Val-HeFT) uncovered a possible adverse interaction among patients on β blockers with concomitant ACE inhibitors and angiotensin receptor blockers (ARBs).
In this paper, we will review the literature describing these controversies, including: 1) the comparability among β blockers; 2) the utility of β blockers among patients with NYHA class I and class IV symptoms; 3) the impact of race on the efficacy of β blockers; and 4) the safety and efficacy of β blockers among patients on concomitant therapy with ACE inhibitors, ARBs, or spironolactone.
Recent evidence from randomized controlled trials has provided compelling evidence to support the use of β blockers in most patients with heart failure due to systolic dysfunction. There is little disagreement about the mortality benefit provided by adding β blockers to standard therapy, which may include angiotensin-converting enzyme inhibitors, diuretics, and sometimes digoxin. A few areas are still controversial. The authors review the available literature encompassing four of those controversial areas: 1) the comparability among β blockers; 2) the utility of β blockers among patients with New York Heart Association class I and class IV heart failure symptoms; 3) the impact of race on the effectiveness of β blockers; and 4) the safety and efficacy of β blockers among patients on concomitant therapy with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or spironolactone.
Recent trials have provided compelling evidence to support the use of β blockers in heart failure (HF) due to systolic dysfunction. Current, major published guidelines support this concept and offer guidance on how to administer them in appropriate patients. Still, there are controversies.
The majority of patients with HF may derive long-term benefit from the addition of β blockers to background therapy, which may include an-giotensin-converting enzyme (ACE) inhibitors, loop diuretics, and digoxin. Only one comparative trial between β blockers in heart failure has been completed. This trial did not resolve the issue of comparability. Little clinical data exists among patients with New York Heart Association (NYHA) class I symptoms and some controversy remains over the appropriateness of routine administration to patients with NYHA class IV symptoms. Additionally, retrospective analyses of prior HF trials and one recently completed β -blocker trial have raised the specter of racial differences in the response of HF patients to pharmacologic therapy. Finally, there also remains uncertainty about how β blockers may interact with other medications. Evidence for the efficacy of β blockers was being gathered at the same time that spironolactone was being evaluated for its use in HF in the Randomized Aldactone Evaluation Study (RALES). As a result, none of the β -blocker trials were conducted with spironolactone as part of background therapy and only 10% of the RALES population was on β blockers. The recently released Valsartan Heart Failure Trial (Val-HeFT) uncovered a possible adverse interaction among patients on β blockers with concomitant ACE inhibitors and angiotensin receptor blockers (ARBs).
In this paper, we will review the literature describing these controversies, including: 1) the comparability among β blockers; 2) the utility of β blockers among patients with NYHA class I and class IV symptoms; 3) the impact of race on the efficacy of β blockers; and 4) the safety and efficacy of β blockers among patients on concomitant therapy with ACE inhibitors, ARBs, or spironolactone.
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