b-blockers in heart failure with low EF

BMJ did a recent meta-anal of b-blockers in pts with chf with decreased ejection fraction. 21 studies with 23K pts, median age 61, 77% men, median LVEF 25%, analyzing data on different b-blockers (most studies with carvedilol), followed median 12 months, assessing primary endpoint of all-cause death (see chf bblockers reduced EF metaanal bmj 2013 in dropbox). overall conclusion  was that there was not much difference between the many b-blockers analyzed (carvedilol, atenolol, metoprolol, bucindilol, bisoprolol or nebivolol), with average RR 0.69 (ie, 31% reduction). a few points:

--generic b-blockers (eg carvedilol, metoprolol, bisoprolol) have the best data ( there was only one study with atenolol, though it was not statistically significant different from any of the ones tested)
--carvedilol had the best (not statistically significant) decrease in mortality (40%) with absolute risk reduction of 6.6%. perhaps attrib to its effects as antioxidant, improving endothelial function, decreased effects on glycemic control in diabetics related to its increase in insulin sensitivity and decrease in microalbinurea).  but it is BID, which is hard for some patients.
--similar effects on improving LVEF (though bucindolol was a little better)
--similar discontinuation rates (though carvedilol was a little better tolerated, esp in the recent COMET trial)

so, mortality benefit of b-blockers seems to be a class effect. my own bias is to use carvedilol, since it has the best data and a trend to better outcomes, though it is a BID drug and requires a pretty slow titration up. But if someone is already on another b-blocker (eg atenolol) and tolerating it well, i would be hesitant to change the regimen given the lack of firm data against any of the above b-blockers and my prior experiences of being unsuccessful in making drug transitions (pt not tolerate the new drug, getting confused about meds/med changes, requiring more frequent clinic visits to assess tolerance and efficacy, etc)


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