Beta-blockers in heart failure – what is the impact of concurrent atrial fibrillation?            

Beta-blockers form an essential cornerstone of therapy for heart failure with reduced ejection fraction. However, the benefits of beta-blockade for heart failure in patients with concurrent atrial fibrillation are less certain. In this meta-analysis of individual-patient data from 10 randomized control trials comparing beta-blockers to placebo for systolic heart failure, investigators assessed the impact of beta-blockade by the presence of sinus rhythm or atrial fibrillation at baseline. Of the 18,254 patients assessed, 76% were in sinus rhythm and 17% were in atrial fibrillation at baseline. Over 1.5 years of mean follow-up, beta-blocker therapy was associated with a significant mortality benefit in sinus rhythm patients (HR 0.73, 0.67-0.80; p<0.001) but not in patients with atrial fibrillation (HR 0.97, 0.83-1.14; p=0.73). Results did not vary by subgroup of patients with atrial fibrillation or for secondary outcomes which included cardiovascular death, cardiovascular hospital admission, and non-fatal stroke.

Conclusion

The benefits of beta-blocker treatment in heart failure appear reduced by concomitant atrial fibrillation. Although the authors suggest β blockers should not be used preferentially for rate control in patients with atrial fibrillation and systolic heart failure, it is important to note this was not a comparative effectiveness study and there is insufficient data to support this conclusion.           

Summarized by Steven M. Bradley and Jehu S. Mathew

  •  Kotecha D, Holmes J, Krum H, Altman DG, Manzano L, Cleland JG, Lip GY, Coats AJ, Andersson B, Kirchhof P, von Lueder TG, Wedel H, Rosano G, Shibata MC, Rigby A, Flather MD, on behalf of the Beta-Blockers in Heart Failure Collaborative G. Efficacy of beta blockers in patients with heart failure plus atrial fibrillation: An individual-patient data meta-analysis. Lancet. 2014 Sep 2. pii: S0140-6736(14)61373-8. doi: 10.1016/S0140-6736(14)61373-8.