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A new trial has provoked fierce debate over which drugs should be used first in heart failure after directly 'challenging' current practice.

The Cardiac Insufficiency Bisoprolol Study III found initiating treatment with a ?-blocker was at least as effective as beginning with an ACE inhibitor.

After six months of treatment, there were 27 per cent fewer deaths in patients who received bisoprolol than in those receiving enalapril.

There were 31 per cent fewer deaths in the bisoprolol group after a further six months' follow-up, although the result fell short of statistical significance.

But study leader Professor Ronnie Willenheimer, director of the cardiology research unit at University Hospital Malmo in Sweden, said: 'CIBIS III challenges the view that treatment of heart failure should be started with an ACE inhibitor. It questions the logic behind that assumption.'

NICE recommends initiating treatment with an ACE inhibitor then adding a ?-blocker.

Professor Willenheimer said: 'The bisoprolol first strategy may offer important advantages in the first year of treatment when the risk of sudden cardiac death is high.'

But Professor John McMurray, professor of medical cardiology at the Western Infirmary in Glasgow, question-ed the methodology of the trial, presented at the European Society of Cardiology congress in Stockholm this week.

He said it had been 'unethical' to deny patients combination treatment for six months.

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