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Benefits of β blockers in patients with heart failure and reduced ejection fraction: network meta-analysis

BMJ 2013; 346 doi: (Published 16 January 2013) Cite this as: BMJ 2013;346:f55

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  1. Saurav Chatterjee, resident1,
  2. Giuseppe Biondi-Zoccai, assistant professor of cardiology2,
  3. Antonio Abbate, assistant professor of cardiology3,
  4. Fabrizio D’Ascenzo, fellow, interventional cardiology4,
  5. Davide Castagno, staff4,
  6. Benjamin Van Tassell, assistant professor3,
  7. Debabrata Mukherjee, chief of cardiology, and acting chairman of medicine5,
  8. Edgar Lichstein, chairman of medicine1
  1. 1Division of Internal Medicine, Maimonides Medical Center, New York, NY, USA
  2. 2Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
  3. 3VCU Pauley Heart Center, Richmond, VA, USA
  4. 4Division of Cardiology, University of Turin, Turin, Italy
  5. 5Division of Cardiology, Texas Tech University, El Paso, TX, USA
  1. Correspondence to: S Chatterjee, 40 Roger Williams Green Apt 40 RWG, Providence, RI 02904, USA sauravchatterjeemd{at}
  • Accepted 28 December 2012


Objective To clarify whether any particular β blocker is superior in patients with heart failure and reduced ejection fraction or whether the benefits of these agents are mainly due to a class effect.

Design Systematic review and network meta-analysis of efficacy of different β blockers in heart failure.

Data sources CINAHL(1982-2011), Cochrane Collaboration Central Register of Controlled Trials (-2011), Embase (1980-2011), Medline/PubMed (1966-2011), and Web of Science (1965-2011).

Study selection Randomized trials comparing β blockers with other β blockers or other treatments.

Data extraction The primary endpoint was all cause death at the longest available follow-up, assessed with odds ratios and Bayesian random effect 95% credible intervals, with independent extraction by observers.

Results 21 trials were included, focusing on atenolol, bisoprolol, bucindolol, carvedilol, metoprolol, and nebivolol. As expected, in the overall analysis, β blockers provided credible mortality benefits in comparison with placebo or standard treatment after a median of 12 months (odds ratio 0.69, 0.56 to 0.80). However, no obvious differences were found when comparing the different β blockers head to head for the risk of death, sudden cardiac death, death due to pump failure, or drug discontinuation. Accordingly, improvements in left ventricular ejection fraction were also similar irrespective of the individual study drug.

Conclusion The benefits of β blockers in patients with heart failure with reduced ejection fraction seem to be mainly due to a class effect, as no statistical evidence from current trials supports the superiority of any single agent over the others.


  • Contributors: SC and GB-Z contributed equally to this work and were responsible for the study concept and design. SC, FD’A, and GB-Z acquired, analyzed, and interpreted the data. SC, AA, FD’A, DC, BVT, DM, and EL drafted the manuscript. AA, BVT, DM, and EL critically revised the manuscript for important intellectual content. SC and GB-Z did the statistical analysis. EL, GB-Z, and DM provided administrative, technical, and material support. EL, DM, and GB-Z provided study supervision. SC and GB-Z are the guarantors.

  • Funding: None.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not needed.

  • Data sharing: Technical appendix, statistical code, and dataset are available from the corresponding author at sauravchatterjeemd{at}

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