Elderly patients hospitalized with heart failure who go on beta
blockers for the first time and continue them after discharge can
expect prolonged survival and fewer rehospitalizations, unless they
are one of the many with preserved systolic function, suggests an
analysis based on a large prospective registry [1]. The findings,
which appear in the January 13, 2009 issue of the Journal of the
American College of Cardiology, are consistent with the few other
studies of beta blockade in comparable patients and highlight how
poorly understood preserved¡Vejection-fraction heart failure is
compared with systolic heart failure.

The adjusted one-year mortality for patients in the analysis who
were discharged on beta blockers was reduced by a significant 23%
among those with systolic dysfunction but not at all, statistically,
among patients with preserved systolic function. There was also a
significant drop in readmissions on beta blockade in the former
group but not the latter. All of the >7000 patients in the analysis,
from the Organized Program to Initiate Lifesaving Treatment in
Hospitalized Patients With Heart Failure (OPTIMIZE-HF) registry, had
been eligible for beta blockade but weren't on them when
hospitalized.

The patients averaged about 80 years in age, slightly younger for
the group discharged on beta blockers.

Clearly, there is powerful evidence for significant benefit from
certain beta blockers in systolic heart failure, observed lead
author Dr Adrian F Hernandez (Duke Clinical Research Institute,
Durham, NC). But based on this analysis and some other data, he told
heartwire, beta blockers are not the answer for heart failure with
preserved systolic function--although such patients may find them
beneficial if they also have diabetes, hypertension, or other
indications for the drugs.

"Certainly our findings are disappointing and, on the heels of I-
PRESERVE, clearly demonstrate that for half the population with
heart failure, we need, one, to understand more about their
pathophysiology, and two, to develop different targets for their
treatment," according to Hernandez.

The I-PRESERVE trial, as recently reported by heartwire, found no
effect on mortality or CV events from the angiotensin-receptor
blocker irbesartan (Avapro, Bristol-Myers Squibb/Sanofi-Synthelabo)
over a four-year follow-up of patients with heart failure and
preserved systolic function.

Such patients typically account for about half of all heart failure
in most reports. In the current analysis, they represented closer to
60%. Systolic dysfunction was defined as an LVEF <40% or qualitative
documentation of systolic dysfunction, while preserved systolic
function meant LVEF >40% or qualitative documentation of preserved
systolic function.

Importantly, the analysis also underscores the poor prognosis faced
by preserved¡Vsystolic-function heart-failure patients, according to
Hernandez. Their one-year mortality was about 32%, and
rehospitalization rate was about 65%. "They're still the elephant in
the room. We still don't know what to do with them."

The ongoing, government-funded Treatment of Preserved-Cardiac-
Function Heart Failure (TOPCAT) trial, Hernandez observed, is
exploring whether the aldosterone inhibitor spironolactone will
improve their outcomes.

The study was supported by GlaxoSmithKline.


Hernandez AF, Hammill BG, O'Connor CM, et al. Clinical effectiveness
of beta-blockers in heart failure. Findings from the OPTIMIZE-HF
(Organized Program to Initiate Lifesaving Treatment in Hospitalized
Patients With Heart Failure) registry. J Am Coll Cardiol 2009;
53:184-192).