Controversies in the Use of Beta Blockers in Heart Failure

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/94510/1/j.1527-5299.2003.00294.x.pd

Caveat anicula! Beware of quiet little old ladies: Demographic features, pharmacotherapy, readmissions and survival in a 10-year cohort of patients with heart failure and preserved systolic function

Objective--To determine whether heart failure with preserved systolic function (HFPSF) has different natural history from left ventricular systolic dysfunction (LVSD). Design and setting--A retrospective analysis of 10 years of data (for patients admitted between 1 July 1994 and 30 June 2004, and with a study census date of 30 June 2005) routinely collected as part of clinical practice in a large tertiary referral hospital.Main outcome measures-- Sociodemographic characteristics, diagnostic features, comorbid conditions, pharmacotherapies, readmission rates and survival.Results--Of the 2961 patients admitted with chronic heart failure, 753 had echocardiograms available for this analysis. Of these, 189 (25%) had normal left ventricular size and systolic function. In comparison to patients with LVSD, those with HFPSF were more often female (62.4% v 38.5%; P = 0.001), had less social support, and were more likely to live in nursing homes (17.9% v 7.6%; P < 0.001), and had a greater prevalence of renal impairment (86.7% v 6.2%; P = 0.004), anaemia (34.3% v 6.3%; P = 0.013) and atrial fibrillation (51.3% v 47.1%; P = 0.008), but significantly less ischaemic heart disease (53.4% v 81.2%; P = 0.001). Patients with HFPSF were less likely to be prescribed an angiotensin-converting enzyme inhibitor (61.9% v 72.5%; P = 0.008); carvedilol was used more frequently in LVSD (1.5% v 8.8%; P < 0.001). Readmission rates were higher in the HFPSF group (median, 2 v 1.5 admissions; P = 0.032), particularly for malignancy (4.2% v 1.8%; P < 0.001) and anaemia (3.9% v 2.3%; P < 0.001). Both groups had the same poor survival rate (P = 0.912). Conclusions--Patients with HFPSF were predominantly older women with less social support and higher readmission rates for associated comorbid illnesses. We therefore propose that reduced survival in HFPSF may relate more to comorbid conditions than suboptimal cardiac management

Classification of the level of evidence in international guidelines for acute and chronic heart failure

Over the centuries, medicine has evolved as a system of care dependent on magic and superstition, fashion, a large placebo effect, self-confident physicians, the fears of patients, and some astute observations. More recently, attempts have begun to put medical care on a more scientific basis by making observations on large numbers of patients to evolve rational constructs for why treatments are effective or fail and ultimately by putting theory and observation to the test in randomized controlled trials. It will be a long time before the science of medicine has eliminated, replaced, or endorsed the current practices and dogma of medical treatment, but a start must be made if future generations of patients are to avoid potentially unnecessary or harmful traditional treatments. Chronic aspirin therapy (1, 2, 3, 4), cosmetic angioplasty (5), and intravenous inotropic therapy (6,7) are just three examples of unproven and potentially wasteful or harmful interventions that are widely practiced due to the failure of doctors to understand the evidence presented to the

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM)

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