In the 1980s we taught medical students and residents not to use beta blockers in CHF (because of the negative inotropic properties). In those days we thought of CHF as a contractile disorder first and a hemodynamic disorder secondary. These days we understand CHF first as a neurohormonal disorder and then a hemodynamic disorder. Research increasingly supports using beta blockers for chronic heart failure. A study in today’s JAMA documents the safety and benefit of beta blockers in patients with severe CHF – who are euvolemic . Let me stress that one more time, they did not start beta blockers until patients became euvolemic.
Effects of Initiating Carvedilol in Patients With Severe Chronic Heart Failure describes the outcomes of starting CHF patients with ejection fractions of less than 25%.
Results
The carvedilol group experienced no increase in cardiovascular risk but instead had fewer patients who died (19 vs 25; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.41-1.35); who died or were hospitalized (134 vs 153; HR, 0.85; 95% CI, 0.67-1.07); or who died, were hospitalized, or were permanently withdrawn from treatment (162 vs 188; HR, 0.83; 95% CI, 0.68-1.03). These effects were similar in direction and magnitude to those observed during the entire study, and were apparent particularly in the 624 patients with recent or recurrent decompensation or a very depressed left ventricular ejection fraction. Differences in favor of carvedilol became apparent as early as 14 to 21 days following initiation of treatment. Worsening heart failure was the only serious adverse event with a frequency greater than 2% and was reported with similar frequency in the placebo and carvedilol groups (6.4% vs 5.1%).
I find these stunning results. Carvedilol less often than placebo worsened CHF. They decrease mortality or hospitalizations. We assume this is a class effect (although we are waiting for a study comparing carvedilol and metoprolol currently underway). We should all remember to use beta blockers in these patients. We do this regularly on my inpatient service, without clinical difficulty.
