CORRESPONDENCE: LETTER TO THE EDITOR
Beta-Blockers in Elderly Patients With Heart FailureReady for Prime Time?
Mitja Lainscak, MD, PhD*,
Hans-Dirk Duengen, MD and
Stefan D. Anker, MD, PhD
* Division of Cardiology, University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, SI-4204 Golnik, Slovenia (Email: mitja.lainscak{at}guest.arnes.si).
We congratulate Hernandez et al. (1) for this important paper on the prognostic impact of beta-blockers in elderly community patients with heart failure (HF). The current evidence suggests beta-blocker use beyond any doubt but in rather limited patient populations (2). Large-scale randomized trials primarily included white male subjects with left ventricular systolic dysfunction due to ischemic heart disease, whereas the guidance in elderly patients or those with preserved left ventricular systolic function is less robust (2,3). Hence, guidelines implementation in eligible patients is unsatisfactory (4) and largely driven by patient age and left ventricular function (5).
Although beta-blockers have gained an indisputable status in patients with HF, it remains unclear whether we should pursue target doses in the elderly population or whether clinical benefit could be gained with lower doses. Previous epidemiological studies demonstrated failure to reach guideline beta-blocker dose in more than one-half of real-world patients with HF (6), even in those managed by cardiologists (7). According to the current report of Hernandez et al. (1) and previous reports (8), it is plausible not to withhold beta-blockers when discharging elderly patients with HF and left ventricular systolic dysfunction. In this context, current European Society of Cardiology guidelines (2) suggest less-tight up-titration than dictated by major trials. Whether up-titration of beta-blockers per landmark trials protocol is feasible and safe in elderly patients with HF has never been tested head-to-head, but we need to know this to make clinical use of the results shown by Hernandez et al. (1). The CIBIS-ELD (Cardiac Insufficiency Bisoprolol Study in Elderly) trial aims to fill in this gap (9). Patients with HF and left ventricular dysfunction (either systolic or diastolic or both) ages >65 years were randomized in a double-blind, double-dummy manner to bisoprolol or carvedilol to test tolerability, safety, and feasibility of a 2-week escalating dose titration scheme to target dose. Whatever the results of the CIBIS-ELD trial, the clinical message by Hernandez et al. (1) should be interpreted and implemented for patient benefit. Nonetheless, for optimal care of patients with HF, we still need to know how to use beta-blockers most effectively. The CIBIS-ELD trial, which completed 3-month follow-up late in 2008, is expected to report shortly and could importantly influence our clinical practice.
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1. Hernandez AF, Hammill BG, O'Connor CM, et al. Clinical effectiveness of beta-blockers in heart failure: findings from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry J Am Coll Cardiol 2009;53:184-192.[Abstract/Free Full Text]2. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 Eur J Heart Fail 2008;10:933-989.[Free Full Text] 3. Flather MD, Shibata MS, Coats AJS, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS) Eur Heart J 2005;26:215-225.[Abstract/Free Full Text] 4. Lain  ak M, Cleland JGF, Lenzen MJ, Follath F, Komajda M, Swedberg K. International variations in the treatment and co-morbidity of left ventricular systolic dysfunction: data from the EuroHeart Failure survey Eur J Heart Fail 2007;9:292-299.[Abstract/Free Full Text] 5. Komajda M, Follath F, Swedberg K, et al. The EuroHeart Failure survey programme—a survey on the quality of care among patients with heart failure in Europe; Part 2: treatment Eur Heart J 2003;24:464-475.[Abstract/Free Full Text] 6. Krum H, Hill J, Fruhwald F, et al. Tolerability of beta-blockers in elderly patients with chronic heart failure: the COLA-II study Eur J Heart Fail 2006;8:302-307.[Abstract/Free Full Text] 7. Lainscak M, Moullet C, Schön N, Tendera M. Treatment of chronic heart failure with carvedilol in daily practice: the SATELLITE survey experience Int J Cardiol 2007;122:149-155.[CrossRef][Web of Science][Medline] 8. Gattis WA, O'Connor CM, Gallup DS, Hasselblad V, Gheorghiade M, IMPACT-HF Investigators and Coordinators Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial J Am Coll Cardiol 2004;43:1534-1541.[Abstract/Free Full Text] 9. Düngen HD, Apostolovic S, Inkrot S, et al. Bisoprolol vs. carvedilol in elderly patients with heart failure: rationale and design of the CIBIS-ELD trial Clin Res Cardiol 2008;97:578-586.[CrossRef][Web of Science][Medline]
Related Article
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Clinical Effectiveness of Beta-Blockers in Heart Failure: Findings From the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) Registry
- Adrian F. Hernandez, Bradley G. Hammill, Christopher M. O'Connor, Kevin A. Schulman, Lesley H. Curtis, and Gregg C. Fonarow
J. Am. Coll. Cardiol. 2009 53: 184-192.
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