Beta-blockade today: the gap between evidence and practice

Current European Society of Cardiology guidelines for chronic heart failure (CHF) recommend the use of beta-blockers in all symptomatic patients with systolic dysfunction. Beta-btockers reduce CHF mortality by >30% and also reduce hospitalizations. Given at appropriate doses, they are generally well tolerated, even in the elderly. However, two large European surveys [IMPROVEMENT in primary care and Euro Heart Failure Survey (EURO-HF) in hospitalized patients) show that beta-blockers are used in only 34-37% of patients, with a wide variation between countries. The frequency of beta-blocker prescription in patients >75 years of age is <20%. A recent analysis of EURO-HF showed that, even among CHF patients who met the criteria for the landmark trials, without comorbidities or other risk factors, beta-blockers are used in <50% of cases. General practitioners and internists prescribe beta-blockers less frequently than cardiologists. This difference may be partly due to the fact that patients treated by non-speciatists tend to be older and have more comorbidities. Another problem is the fear of side effects with beta-blockers. This is often due to lack of experience (particularly among primary care physicians), as in the past beta-blockers were considered contraindicated in CHF. Frequently cited reasons for not prescribing beta-blockers are advanced age, severe symptoms, and comorbidities (e.g. chronic lung disease, diabetes). In fact, most problems can be avoided if beta-blockers are started at a very low dose and titrated up step by step to the maximum tolerated dose. Mortality benefits are achieved even at doses much lower than the targets used in clinical trials. The CIBIS III results should now help to eliminate most of the doubts regarding the efficacy and tolerability of beta-blockade, even in the elderly patient population.