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PRACTICE: Henry Krum Consider β blockers for patients with heart failure BMJ 2009; 338: b1728 [Full text]

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Wheeze in cardiac failure – a true reflection of lower airway obstruction?

William E Moody   (8 June 2009)

What are the barriers to implementing beta-blocker prescribing for people with heart failure?

Duncan Petty, Jon Silcock, Theo Raynor, Arnold Zermansky   (11 June 2009)

Wheeze in cardiac failure – a true reflection of lower airway obstruction? 8 June 2009
William E Moody, ST2 cardiology, West Midlands Deanery Solihull Hospital, Heart of England NHS Foundation Trust Send response to journal: Re: Wheeze in cardiac failure – a true reflection of lower airway obstruction?	I read with interest Krum’s eye-opening review on the barriers to initiation of beta-blockers in patients with heart failure. With ischaemia the commonest cause for left ventricular dysfunction and smoking a well established risk factor for ischaemic heart disease, it is not surprising that many patients with heart failure have significant pack year histories behind them. After the development of some non-specific wheeze, many of these patients are started on inhaler therapy which later puts off many doctors ever even considering beta-blockade. I would strongly urge clinicians to seek objective evidence of reversible airflow obstruction via spirometry before condemning this potentially vast population to a life without beta-blockers. References 1. Krum H. Consider beta-blockers for patients with heart failure. BMJ 2009;338;b1728 Competing interests: None declared
What are the barriers to implementing beta-blocker prescribing for people with heart failure? 11 June 2009
Duncan Petty, Research Pharmacist School of Healthcare, University of Leeds, LS2 9UT, Jon Silcock, Theo Raynor, Arnold Zermansky Send response to journal: Re: What are the barriers to implementing beta-blocker prescribing for people with heart failure?	Henry Krum 1 makes the observation that whilst beta-blockers are effective treatments for heart failure they remain under-used. The main barrier to change in practice is assumed to be the long held belief that beta-blockers are contraindicated in heart failure. We recently tested this idea in a small survey of UK medical general practitioners (GPs). 2 A questionnaire was sent to GPs in Bradford, United Kingdom. It asked two questions on the perceived benefits of beta-blockers in heart failure and two on the perceived risks. When answering the questions, participants were given a scenario of a patient with stable mild to moderate heart failure; on optimum treatment with an ACE-I and loop diuretic (e.g. furosemide), and no known contraindications to beta blockers. The evidence for the “correct” answers was taken from the publication Clinical Evidence. 3 One hundred and eighty questionnaires were sent and 69 (38%) returned. The average number of years since qualification was 17 (range 4 to 40 years). There was no correlation between responses given and years since qualification. All respondents correctly thought beta-blockers would save lives and the majority though beta-blockers would cause fewer hospitalisations. Adverse effects from beta blockers compared to data from clinical trials were underestimated. 2 GPs gave responses that were in line with the clinical evidence. Yet despite giving the correct responses, only 34% of their patients with heart failure were being treated with beta-blockers. 2 It appears that some UK GPs may know what the evidence says but do not apply this to their patients. This might be because some GPs lack the confidence to use beta- blockers in heart failure. The British National Formulary recommends that beta-blockers should be initiated by “those experienced in the management of heart failure.” 4 The National Institute of Health and Clinical Excellence heart failure guidelines say this can include GPs and other clinicians with a specialist interest in the condition, and do not say that beta-blockers should only be initiated by a specialist. 5 GPs can find it difficult to change treatment initiated by a cardiologist, including initiating ACE-I in patients already stable on their current medication.6 It may be, therefore, that GPs consider the management of drug treatment for heart failure as a specialist role. This is compounded by the problem that specialists may not be able to start beta-blockers during the acute phase of heart failure (i.e. during an admission). If patients are discharged without a beta-blocker then GPs may not consider it their role to initiate therapy when the patient is stable. The lack of a shared-care approach between primary and secondary care may result in a ’collusion of anonymity’ whereby neither GPs nor specialists take responsibility for optimal management. References 1. Krum H. Consider beta-blockers for patients with heart failure. BMJ 2009; 338 ;b1728. 2. Petty, D; Silcock, J; Zermansky, A; Raynor, DK Theo. A survey of general practitioners' perceptions of beta-blocker therapy for heart failure. International Journal of Pharmacy Practice , Supplement 2, 29-30, 2007. 3. Beta blockers for heart failure. Clinical Evidence. Available online at http://www.clinicalevidence.com/ceweb/conditions/cvd/0204/0204_I6.jsp 4. British National Formulary (BNF) Section 2.4. British Medical Association/ Royal Pharmaceutical Society of Great Britain. Pharmaceutical Press, London (2009). 5. NICE guideline No 5. Chronic Heart Failure. National clinical guideline for diagnosis and management in primary and secondary care. Royal College of Physicians, London 2003. 6. Kasje WN, Denig P, de Graeff PA, Haaijer-Ruskamp FM. Perceived barriers for treatment of chronic heart failure in general practice; are they affecting performance? BMC Family Practice 2005, 6:19; doi:10.1186/1471-2296-6-19. Competing interests: None declared