Beta-blockade as First-line Therapy in the Elderly Heart Failure Patient—the Proper Approach or Asking for Trouble?

Abstract

After a long and tedious start, beta-blockade has undeniably become one of the pillars of heart failure therapy. Based on the positive results of large, controlled studies in patients with stable mild, moderate and advanced chronic heart failure, beta-blocking drugs have been approved for the treatment of this syndrome, and are well positioned in national and international guidelines for the treatment of heart failure [1]. Of importance, their beneficial effects are comparable irrespective whether patients are at low, intermediate or high risk of heart failure. The same is true for different age groups. Indeed, elderly heart failure patients clearly benefit from long term beta-blocker therapy. The latter is important, as the heart failure patient in the community is relatively old, on average 74 years, in contrast to the average age (around 60–62 years) of the typical patient recruited in heart failure drug trials, including most studies with beta-blocking agents [2–5]. In the latter studies, beta-blocking therapy has on average been well tolerated. Although one could argue that this may be related to the relatively young age in these studies, a more recent study in elderly heart failure patients, SENIORS, also indicated that these patients (average age 76 years) tolerated beta-blockade well, comparable to placebo [6]. Of importance, in each of these studies beta-blockade was administered in addition to optimal heart failure therapy, which includes ACE inhibition and /or angiotensin receptor blockade in approximately 90% of patients. It is conceivable that, in this way, patients may have been protected from a potential adverse effect of the betablocker, worsening heart failure, and therewith may have tolerated the beta-blocker so well. This, of course, would be a perfect argument in favour of always first prescribing an ACE inhibitor (or ARB in those patients who do not tolerate ACE inhibition) and then follow up with a beta-blocker; exactly as current guidelines mandate [1]. However, and despite the apparent logic, is it really always necessary to follow this order of treatment? The fact that ACE inhibitors have become first choice in heart failure is purely based on historical grounds, placebocontrolled ACE inhibitor trials being performed a decade before those with beta-blockade. The obvious beneficial effects of ACE inhibition in these early trials (with only digitalis and diuretics as background medication) has made it unethical in many eyes to conduct studies without the ACE inhibitor as concomitant therapy [7] The drawback of this is that it is difficult if not impossible to determine the specific effects of different therapies, such as beta-blockade, in heart failure as well as their usefulness as first-line therapy. With this in mind, are there grounds on which to expect a better (or at least similar) efficacy of beta-blockade than ACE inhibition in mild to moderate heart failure, usually the time when the choice of first-line therapy will be made? Cardiovasc Drugs Ther (2008) 22:347–350 DOI 10.1007/s10557-008-6126-7