What is the most effective beta-blocker for heart failure?

Journal of Family Practice, May, 2003 by Jon O. Neher

Beta-blockers aid the failing heart in several ways:

* Slow the heart rate

* Reduce the myocardial contractility

* Increase vasodilation (carvedilol, metoprolol)

Through dilation of peripheral arteries and veins, ACE inhibitors enchance left ventricular function by reducing filling pressure and systemic resistance.

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TABLE
Selected trials of beta-blockers for systolic dysfunction

                                        Mortality
                                        reduction   95%
Study               Drug         N      (%)         CI (%)

US Carvedilol (1)   Carvedilol   1094   (65)         39-80
COPERNICUS (2)      Carvedilol   2289   (35)         19-48
MERIT-HF (3)        Metoprolol   3991   (34)         19-46
CIBIS II (4)        Bisoprolol   2647   (34)         19-47
BEST (5)            Bucindolol   2708   (9)         -0.2-22

                                          Mean duration
                    Statistically         of follow-up
Study               significant?    NNT   (months)

US Carvedilol (1)   Yes             22    6.5
COPERNICUS (2)      Yes             14    10.4
MERIT-HF (3)        Yes             26    12
CIBIS II (4)        Yes             18    15.6
BEST (5)            No              --    24

CI, confidence interval; NNT, number needed to treat

REFERENCES

(1.) Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med 1996; 334:1349-1355.

(2.) Packer M, Coats AJS, Fowler MB, et al. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med 2001; 344:1651-1658.

(3.) Effect of metoprolol CR/XL in chronic heart failure: Metotprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 353:2001-2007.

(4.) The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999; 353:9-13.

(5.) A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure. N Engl J Med 2001; 344:1659-1667.

(6.) Hart SM. Influence of beta-blockers on mortality in chronic heart failure. Ann Pharmacother 2000; 34:1440-1451.

(7.) Metra M, Giubbini Raffaele, Nodari E, Boldi E, Modena MG, Dei Cas L. Differential effects of beta-blockers in patients with heart failure: A prospective, randomized, double-blind comparison of the long-term effects of metoprolol versus carvedilol. Circulation 2000; 102:546-551.

(8.) Poole Wilson PA, Cleland JG, Di Lenarda A, et al. Rationale and design of the carvedilol or metoprolol European trail in patients with chronic heart failure: COMET. Eur J Heart Fail 2002; 4:321-329.

(9.) Aronow WS, Ahn C, Kronzon AI. Effect of propranolol versus no propanolol on total mortality plus nonfatal myocardial infarction in older patients with prior myocardial infarction, congestive heart failure, and left ventricular ejection fraction [greater than or equal to] 40% treated with diuretics plus angiotensin-converting enzyme inhibitors. Am J Cardiol 1997; 80:207-209.