1. Which Beta-Blocker is Best for Patients with Heart Failure? Summary and Comment by Joel M. Gore, MD Published in Journal Watch Cardiology December 17, 2008Journal Watch Cardiology Evidence of efficacy might not be the most important factor to consider. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

2. Covering Kramer JM et al. Comparative effectiveness of β-blockers in elderly patients with heart failure. Arch Intern Med 2008 Dec 8; 168:2422. Go AS et al. Comparative effectiveness of different β-adrenergic antagonists on mortality among adults with heart failure in clinical practice. Arch Intern Med 2008 Dec 8; 168:2415. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

3. Background Treatment of systolic heart failure with beta-blockers has been shown to reduce cardiovascular morbidity and mortality, but which beta-blocker to use is the subject of debate. In two independent observational studies, investigators assessed the comparative effectiveness of different beta-blockers in patients with heart failure. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

4. The Research In the first study, the authors identified nearly 12,000 patients aged 65 or older in North Carolina Medicaid and Medicare records from 2001 through 2004 who had had at least one hospitalization for heart failure. The researchers assessed mortality from 30 days to 1 year after discharge in patients taking the evidence-based beta-blockers (EBBBs) carvedilol, metoprolol succinate, and bisoprolol (23%); in patients taking non–evidence-based beta-blockers (non-EBBBs; 18%); and in patients taking no beta-blockers (59%). Propensity adjustment resulted in well-balanced baseline characteristics among the groups. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

5. The Research In both unadjusted and adjusted analyses, 1-year mortality was significantly higher in the group receiving no beta-blockers (28.3%, adjusted) than in either the non-EBBB group (22.8%) or the EBBB group (24.2%); the difference between the death rates in the non- EBBB and EBBB groups was statistically nonsignificant. Significantly more rehospitalizations occurred in patients receiving EBBBs than in those receiving either no beta-blockers or non- EBBBs. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

6. The Research In the second study, investigators used data from two large U.S. healthcare systems to evaluate more than 11,000 patients (mean age, 74) who survived hospitalization for heart failure between 2001 and 2004. At discharge or during 12 months of follow-up, 7976 patients received beta-blockers: atenolol (38%), metoprolol tartrate (43%), carvedilol (12%), or others (7%). The mortality rate (per 100 person-years) was lowest in patients taking carvedilol (17.7%), followed by atenolol (20.1%), other beta- blockers (21.9%), and metoprolol tartrate (22.8%). Compared with patients taking atenolol, and adjusted for confounders and the propensity to receive carvedilol, the risk for death was significantly increased in those taking metoprolol tartrate (hazard ratio, 1.16) or no beta-blockers (HR, 1.63), but not in those taking carvedilol. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

7. Comment The results of these two studies underscore the importance of following guideline recommendations to use beta-blockers in all patients with heart failure caused by LV systolic dysfunction, regardless of their age. The findings suggest that metoprolol tartrate is not as effective as is atenolol or carvedilol. Whether evidence-based beta-blockers (e.g., carvedilol) are generally superior to non–evidence-based beta-blockers (e.g., atenolol) can be conclusively determined only by large-scale randomized trials. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

8. About Journal Watch Journal Watch helps physicians and allied heath professionals save time and stay informed by providing brief, clearly written, clinically focused perspectives on the medical developments that affect practice. Journal Watch is an independent, trustworthy source, from the publishers of the New England Journal of Medicine. These slides were derived from Journal Watch Cardiology.Journal Watch Cardiology The best way to stay informed with Journal Watch, is through our alerts. To sign up, visit the My Alerts page.My Alerts page CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society