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Tolerability and Feasibility of Beta-Blockers in Elderly Heart Failure Patients
Study Questions:
What is the tolerability and feasibility of titration of two distinctly acting beta-blockers (BBs) in elderly heart failure (HF) patients with preserved (HFpEF) and reduced (HFrEF) left ventricular ejection fraction (LVEF)?
Methods:
The study cohort included patients enrolled in the CIBIS-ELD (Comparison of Bisoprolol and Carvedilol in Elderly Heart Failure Patients: A Randomised, Double-Blind Multicentre Study) trial, which randomized patients >65 years of age with HFrEF (LVEF ≤45%, n = 626) or HFpEF (LVEF >45%, n = 250), to bisoprolol or carvedilol. In this study, both BBs were up-titrated to the target or maximum tolerated dose. Follow-up was performed after 12 weeks. The study authors compared HFrEF and HFpEF patients regarding tolerability and clinical effects (heart rate, blood pressure, systolic/diastolic function, New York Heart Association (NYHA) class, 6-minute walking distance, quality of life, and N-terminal pro–B-type natriuretic peptide).
Results:
The study authors found that there was greater improvement in NYHA class in HFrEF (HFpEF 23% vs. HFrEF 34%, p < 0.001), although similar reductions in heart rate were observed in both groups (HFpEF -6.6 bpm, HFrEF -6.9 bpm, not significant). There were no significant differences between bisoprolol and carvedilol with regard to clinical parameters in either group. Tolerability and daily dose at 12 weeks were similar for both BBs. There were higher rates of dose escalation delays and treatment-related side effects in HFpEF patients. Mean E/e’ and left atrial volume index did not change in either group, although E/A increased in HFpEF.
Conclusions:
The authors concluded that BB tolerability was comparable between HFrEF and HFpEF. Relevant reductions of heart rate and blood pressure occurred in both groups. However, only HFrEF patients experienced considerable improvements in clinical parameters and LV function. They concluded that neither BB has any effect on established and prognostic markers of diastolic function.
Perspective:
The greater improvement in NYHA class in patients with HFrEF reflects the fact that it is a hyper-adrenergic state. This study confirms that further clinical trials are needed to determine the best therapy for elderly patients with HFpEF.
Keywords: Adrenergic beta-Antagonists, Bisoprolol, Blood Pressure, Carbazoles, Diastole, Geriatrics, Heart Failure, Maximum Tolerated Dose, Natriuretic Peptide, Brain, Propanolamines, Quality of Life, Stroke Volume, Systole
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