Beta-blocking agents in heart failure. Should they be used and how?

Abstract

Experience accumulated from several large trials strongly suggests that β-blockers should be used for the management of chronic heart failure. It is appropriate to add β-blockade to conventional therapy such as diuretics, ACE inhibitors and digoxin, as this was the approach used in the major trials. It is appropriate to treat patients with mild, moderate and, when stable, severe chronic heart failure. The benefits obtained include improvements in left ventricular function, reductions in symptoms and morbidity, improvement of duality of life, and delay of clinical progression, reflected in a reduced need for cardiac transplantation and, probably, a reduction in mortality. β-blockers are much better tolerated, when used appropriately in selected patients, than was previously supposed. To confirm the improvement in survival recently reported with carvedilol, further prospective trials using different β-blockers are warranted. No major comparative trials have been carried out between β-blockers in chronic heart failure, therefore it is known whether the difference between them are clinically significant. The optimal dose of β-blocker and the effect of patient groups excluded from or poorly represented in the clinical trials (e.g. elderly patients) have yet to be determined. Placebo-controlled mortality trials with bucindolol (BEST) and bisoprolol (CIBIS-II) are under way([)89, 90]. A large study of carvedilol versus metoprolol (COMET), added to conventional treatment, is planned.