Consider β blockers for patients with heart failureBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1728 (Published 01 June 2009) Cite this as: BMJ 2009;338:b1728
All rapid responses
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
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.
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,
3. Beta blockers for heart failure. Clinical Evidence. Available
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;
Competing interests: No competing interests
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.
1. Krum H. Consider beta-blockers for patients with heart failure. BMJ
Competing interests: No competing interests