The evidence for β blockers in heart failure

Equals or surpasses that for angiotensin converting enzyme inhibitors

Heart failure is a common, malignant condition for which hospital admissions are rising rapidly.1^–3 Despite the evidence that angiotensin converting enzyme inhibitors improve the morbidity and mortality of heart failure secondary to left ventricular systolic dysfunction, the prognosis of heart failure in the community has improved little over the past 30 years.4 This may reflect a reluctance to prescribe angiotensin converting enzyme inhibitors.4 Now, however, evidence has accumulated to show that β blockers, when used in addition to angiotensin converting enzyme inhibitors, also reduce mortality in heart failure. Will this be another lost opportunity?

The CIBIS-II study,5 comparing bisoprolol with placebo, recently reported a highly significant reduction in all cause mortality. When these data and those from other smaller trials6^–8 identified from searches of Medline and Embase and recent meetings9 are added to those reported in previous meta-analyses10 there are now 25 trials that have randomised patients with heart failure to β blocker or control, comprising 6511 patients and 810 deaths. Overall β blockers reduced the odds of death by 36% (95% confidence interval 25% to 45%) (fig 1). There is no evidence of heterogeneity between …