Could β-Blockers Precede or Replace Angiotensin-Converting Enzyme Inhibitors in Heart Failure?

Abstract

β-blockade is considered mandatory in heart failure treatment if patients remain symptomatic despite angiotensin-converting enzyme (ACE) inhibition and diuretics. ACE inhibitors are first-line therapy on historical grounds, but in certain individuals, β-blockade may be a better choice. Because this is difficult to assess in long-term controlled clinical endpoint studies for ethical reasons, surrogate endpoints such as cardiac remodeling have been used. Of the available β-blockers, carvedilol provides better comprehensive adrenergic blocking, antioxidant, and antiendothelin effects compared with selective β 1 -blockers bisoprolol and metoprolol. The Carvedilol Remodeling in Mild Heart Failure Evaluation comparing carvedilol and ACE inhibition with enalapril found that the combination most reversed cardiac remodeling. These results support a therapeutic strategy in which the prescription of β-blockade in heart failure should not be delayed.