Efficacy of β-Blockers in Patients With Heart Failure Plus Atrial Fibrillation: An Individual-Patient Data Meta-Analysis
What is the efficacy of β-blockers in patients with heart failure and sinus rhythm, compared to atrial fibrillation?
This was a patient-level meta-analysis of randomized controlled trials of β-blockers versus placebo in heart failure. Baseline electrocardiogram was used to establish the diagnosis of sinus rhythm and atrial fibrillation or atrial flutter. The primary outcome was all-cause mortality.
A total of 18,254 patients were included in the analytic sample; 13,946 (76%) had sinus rhythm and 3,066 (17%) had atrial fibrillation. Although therapy with beta-blockade led to a significant reduction in all-cause mortality in patients with sinus rhythm (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.67-0.80; p < 0.001), it did not in those with atrial fibrillation (HR, 0.97; 95% CI, 0.83-1.14; p = 0.75). In exploratory subgroup analyses, no significant interactions were noted for the following variables: age, sex, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class, blood pressure or heart rate, and medical therapy. For time to first admission for cardiovascular causes, the adjusted HR for patients with sinus rhythm was 0.78; for those with atrial fibrillation, 0.91. Attained heart rate and change from baseline heart rate were similar in both sinus rhythm and atrial fibrillation groups.
Patients with heart failure and atrial fibrillation did not experience a significant reduction in all-cause mortality or cardiovascular hospitalization in this individual-patient data analysis.
There is paucity of data to inform the efficacy of β-blockers in patients with heart failure and concomitant atrial fibrillation, even though they often co-exist. Notwithstanding the limitations associated with meta-analytic techniques, this is an important study that draws question to the preferential use of beta-blockers compared with other rate-control agents in patients with heart failure and atrial fibrillation. That said and although the authors found no evidence that β-blocker therapy prevents major adverse cardiovascular events in patients with both heart failure and atrial fibrillation, the current analysis did establish safety of this strategy in this population (i.e., no increase in mortality or hospital admission rates). As the negative inotropic effect of the non-dihydropyridine calcium channel antagonists may be deleterious in patients with heart failure and given the limitations of digoxin monotherapy (for the purposes of rate control), perhaps β-blocker therapy remains the best option for rate control in those with heart failure and concomitant atrial fibrillation.
Keywords: Dihydropyridines, Digoxin, Heart Failure, Stroke Volume, Blood Pressure, Confidence Intervals, Electrocardiography, Heart Rate, Calcium, ESC Congress
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