Beta-blockers: all are equal, but some more than others

Carvedilol, Metoprolol and Bisoprolol have all been shown to improve outcomes in patients with heart failure. These evidence based beta-blockers (EBBB) are in contrast to atenolol, propranolol, and timolol, which have not been directly tested in heart failure. Therefore if a patient on one of these agents develops heart failure, is it neccesary to switch them to an EBBB?

Kramer et al. looked at patients in North Carolina aged over 65 years old who had been admitted for heart failure at least once.  The primary outcome measure was survival from 30 days to 1 year.  Of 11959 patients, 40% were nonwhite and 79% were female.  23% were receiving EBBBs and 18% were receiving non-evidence based beta-blockers.  At one-year, adjusted mortality rates were 24.2% for patients taking EBBB, compared to 22.8% for patients taking non-evidence based beta-blockers (p=.43); those taking no beta-blockers had a mortality rate of 28.3% (p=0.002 compared to patients taking beta-blockers).  More rehospitalizations were seen in patients taking EBBBs when compared to no beta-blockers (p=0.002) and non-EBBB (p<.001).

This is a retrospective study performed in an elderly cohort.  Were similiar findings to arise from an analysis of a younger heart failure population, then a randomised trial examining the effects of EBBBs vs non-EBBBs could be merited.

  • Kramer JM, Curtis LH, Dupree CS, et al.  Comparative Effectiveness of β-Blockers in Elderly Patients With Heart Failure.  Arch Intern Med. 2008;168(22):2422-2428.