Comparative Effectiveness of β-Blockers in Elderly Patients With Heart Failure—Invited Commentary

Treatment with BBs has been shown to reduce cardiovascular mortality and hospitalizations for HF in large-scale, placebo-controlled, randomized trials of patients with HF caused by left ventricular systolic dysfunction (LVSD).^1- 3 β-Blockers, along with angiotensin-converting enzyme (ACE) inhibitors⁴ and aldosterone-blocking agents,⁵ reduce mortality and hospitalization for HF in patients with HF caused by LVSD and have been given a class 1 indication in the American College of Cardiology/American Heart Association guidelines.⁶ However, despite the overwhelming evidence supporting the use of BBs in patients with HF caused by LVSD, many patients who seem to qualify for their use do not receive them.⁷ In part, this is the result of perceived tolerability, cost, a revulsion on the part of many patients and physicians to the use of polypharmacy, and the belief that randomized clinical trials in circumscribed patient populations do not reflect real-world conditions and do not apply to patients often seen in clinical practice but not included in the pivotal randomized trials, such as elderly individuals. Kramer et al⁸ have now examined close to 12 000 patients 65 years or older, 26% of whom were 85 years or older (mean age, 79 years), with at least 1 HF hospitalization, from the North Carolina Medicare/Medicaid database. They related mortality from 30 days to 1 year after hospitalization for HF to the use of BBs and found that patients prescribed a BB had a substantial reduction in mortality compared with patients not given a BB (59% of patients with HF). These results extend our knowledge concerning the tolerability of BBs in elderly patients with HF and leave little reason, except for known contraindications, for not attempting to use a BB in all patients with HF caused by LVSD.