Letters β blockers for heart failure

Research into “real world” older patients is needed

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3136 (Published 07 June 2016) Cite this as: BMJ 2016;353:i3136
  1. Conal J Cunningham, consultant geriatrician
  1. Falls and Blackout Unit, St James's Hospital, Dublin 8, Republic of Ireland
  1. ccunningham{at}stjames.ie

Kotecha and colleagues’ meta-analysis establishes that β blockers are beneficial in patients aged 40-85 with heart failure and reduced ejection fraction who are able to tolerate them. In the original trials most patients seemed to tolerate these drugs.1

But it does not tell us how well older people in clinical practice can tolerate β blockers, and the authors seem to extrapolate beyond their data. All the randomised controlled trials in the analysis were conducted 10-20 years ago, had exclusion criteria designed to avoid harm (eg previous intolerance to β blockers or worsening heart failure), and had titration periods early in the trial designed to increase doses safely. It is therefore not surprising that most tolerated the drugs.

Although the age range was 40-85 years, the median age of the sample was 64 years, so this was not an elderly group by 2016 standards (probably not by 2000 standards either), and patients aged 85 or more were excluded. As the authors acknowledge, patients with heart failure are much older.

Lastly, β blockers have been found to be associated with a twofold to threefold increase in orthostatic hypotension in older patients with hypertension,2 and their association with falls in very elderly patients is a concern (although not definitively proved). In my clinical practice of treating older people who fall (mean age 80 years) β blockers are often poorly tolerated and have to be stopped. Even when tolerated, the maximal doses achieved in the original trials are rarely obtained.

A more accurate conclusion of this analysis might be that older patients with heart failure and reduced ejection fraction can be trialled on β blockers, but that care must be taken in patient selection and titration period and that a significant minority may not be able to tolerate them. Further research into “real world” older patients is needed before we can conclude, as the authors do, that “intolerance” of β blockers in clinical practice could reflect false attribution to intercurrent events or preconceptions about side effects."


  • Competing interests: None declared.


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