Beta-blockers in heart failure: Is more better?
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Therapies that modulate the sympathetic nervous system and renin-angiotensin-aldosterone system reduce morbidity and mortality in patients with heart failure. However, they are grossly underused in clinical practice; when used, the doses prescribed are substantially smaller than the target doses used in the large-scale studies that established their utility. Whether these suboptimal doses are as effective in reducing morbidity and mortality is largely unknown. This review focuses on the relationship between the dose of β-blockers and their effect on clinical outcomes. Because direct dose comparisons of β-blockers are limited, we draw upon a broader spectrum of clinical trials across the cardiovascular continuum that involved neurohormonal modulators to address the question, ‘Is more better?’
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References and Recommended Reading
- 1.Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. N Engl J Med 1987, 316:1429–1435.Google Scholar
- 2.Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med 1991, 325:293–302.Google Scholar
- 3.Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med 1992, 327:685-691. [Published erratum appears in N Engl J Med 1992, 327:1768.]Google Scholar
- 4.Kober L, Torp-Pedersen C, Carlsen JE, et al.: A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group. N Engl J Med 1995, 333:1670–1676.PubMedCrossRefGoogle Scholar
- 8.The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999, 353:9–13.Google Scholar
- 9.Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999, 353:2001–2007.Google Scholar
- 17.Simon T, Mary-Krause M, Funck-Brentano C, et al.: Bisoprolol dose-response relationship in patients with congestive heart failure: a subgroup analysis in the cardiac insufficiency bisoprolol study (CIBIS II). Eur Heart J 2003, 24:552–559. This retrospective analysis of the CIBIS II trial highlights the importance of dose on prognosis in patients with heart failure.PubMedCrossRefGoogle Scholar
- 19.Baruch L, Anand I, Cohen IS, et al.: Augmented short- and long-term hemodynamic and hormonal effects of an angiotensin receptor blocker added to angiotensin converting enzyme inhibitor therapy in patients with heart failure. Vasodilator Heart Failure Trial (V-HeFT) Study Group. Circulation 1999, 99:2658–2664.PubMedGoogle Scholar
- 20.Parving HH, Lehnert H, Brochner-Mortensen J, et al.: The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001, 345:870–878. This prospective study suggests that higher doses of an ARB confer greater nephroprotection despite similar levels of blood pressure control.PubMedCrossRefGoogle Scholar
- 23.Dickstein K, Kjekshus J: Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan. Lancet 2002, 360:752–760.PubMedCrossRefGoogle Scholar