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Beta blockers ‘should not be prescribed in patients with both atrial fibrillation and heart failure’

Beta blockers should no longer be prescribed as standard therapy in patients with heart failure who also have atrial fibrillation, the authors of a large meta-analysis of randomised trials of the drugs have concluded.

An international team of experts, led by Birmingham University doctors, said beta blockers do not offer any long-term survival advantage to these patients and ‘should not be used preferentially over other rate-control medications’.

GP experts said the findings supported previous evidence questioning the long-term benefits of the drugs for co-existing heart failure and atrial fibrillation but added that advice not to prescribe the drugs in this group was premature and could cause confusion, particularly as QOF rewards their broad use in heart failure patients.

The study looked at ten randomised controlled trials of beta blockers compared with placebo in patients with heart failure, using baseline electrocardiograph data to compare outcomes in patients in sinus rhythm with those with atrial fibrillation.

Among the total 18,254 patients studied, 3,066 had atrial fibrillation at baseline.

The results, presented at the European Society of Cardiology annual congress and published in the Lancet, showed beta-blockers led to a significant 27% reduction in all-cause mortality compared with placebo among patients with sinus rhythm – but no reduction at all in mortality among those with atrial fibrillation.

The researchers said the lack of benefit from beta blockers was observed across all subgroups of atrial fibrillation, including age, sex, left ventricular ejection fraction, New York Heart Association class, heart rate and baseline medical therapy.

They concluded: ‘Based on our findings, beta blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation.’

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Lead author Dr Dipak Kotecha, clinical lecturer in cardiovascular medicine at the University of Birmingham, cautioned in his presentation at the congress that the findings may not apply to patients with preserved systolic function – only 2% of patients in the trials overall had a left ventricular ejection fraction of 50% or higher.

Dr Matthew Fay, GPSI in cardiology in Shipley, who led the recent update of NICE guidelines on atrial fibrillation, told Pulse the findings reflected previous evidence questioning the long-term benefit of beta blockers in patients with atrial fibrillation and systolic dysfunction.

He said: ‘This was known from other studies that beta-blockers do not have the prognostic benefit in left-ventricular systolic dysfunction in people with persistent/permanent atrial fibrillation as they do in sinus rhythm.’

Dr Fay said alternatives for rate control in atrial fibrillation are limited, however. The dihyropyridines diltiazem and verapamil should not be used in patients with heart failure with impaired systolic function, because they are negatively inotropic and ‘tend to make it more asymptomatic’, he said, while research is now suggesting the other alternative digoxin is potentially harmful in atrial fibrillation.

He added: ‘So we are left with beta-blockers to assist in rate control in the symptomatic or tachycardic AF patients and have to accept that there is no prognostic benefit. QOF should change obviously to not incentivise the use of beta blockers in left ventricular systolic dysfunction with atrial fibrillation, as there is no benefit.’

Dr Terry McCormack, secretary of the British Hypertension Society and a GPSI in cardiology in North Yorks, said the findings could cause confusion and should be verified by a randomised trial. He said changing QOF would be very complicated – and agreed that beta blockers may still be valuable for symptom relief even in the absence of long-term prognostic value.

Dr McCormack said: ‘It’s very interesting and could potentially change advice – but it’s complicated. Currently you’re recommended to be on a beta blocker if you’ve got heart failure and similarly if you have got atrial fibrillation – but this suggests if you’ve got both you shouldn’t take it. And how you would write that into QOF would be difficult.’

He added: ‘At the end of the day you need to control the heart rate for symptom relief. I think this could cause a lot of confusion. Guidelines are not going to change because that will take time and discussion – and QOF certainly isn’t until the guidelines changed. At the moment it just puts a doubt in our minds about it.’

Lancet 2014; available online 2 September



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