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Mr Dipak Kotecha
Prof. Lars Ryden,
By Dipak Kotecha, (Birmingham, United Kingdom)View Discussant reportOpen the PresentationWatch the Webcast
List of Authors:
Dipak Kotecha, Jane Holmes, Henry Krum, Douglas G Altman, Luis Manzano, John GF Cleland, Gregory YH Lip, Andrew JS Coats, Bert Andersson, Paulus Kirchhof, Thomas G von Lueder, Hans Wedel, Giuseppe Rosano, Marcelo C Shibata, Alan Rigby and Marcus D Flather, on behalf of the Beta-Blockers in Heart Failure Collaborative Group.
BackgroundAtrial fibrillation (AF) and heart failure (HF) frequently coexist, causing substantial cardiovascular (CV) morbidity and mortality. Beta-blockers are a Class1A indication in symptomatic HF with reduced ejection fraction, however their efficacy in patients with concomitant AF is uncertain.MethodsWe extracted individual patient data from 10 randomised controlled trials comparing beta-blockers versus placebo in HF. The presence of sinus rhythm or AF was determined from the baseline electrocardiogram. Outcome data were meta-analysed using adjusted Cox proportional hazards regression and are presented as hazard ratios (HR) with confidence intervals.ResultsA total of 18,254 participants were assessed, of which 13,946 (76.4%) were in sinus rhythm and 3,066 (16.8%) in AF. Crude death rates over a mean follow-up of 1.5 years (SD 1.1) were 16.0% in sinus rhythm and 20.7% in AF. Beta-blocker therapy in patients with sinus rhythm led to a significant reduction in all-cause mortality (HR 0.73, 0.67-0.80; p<0.001) and CV-hospitalisation (HR 0.78, 0.73-0.83; p<0.001), as well as CV-death, HF-hospitalisation, the composite of all-cause mortality/CV-hospitalisation and the composite of CV-death/HF-hospitalisation. In contrast, there was no apparent effect from beta-blockers on any outcome in patients with AF, including mortality (HR 0.97, 0.83-1.14; p=0.73) and CV-hospitalisation (HR 0.91, 0.79-1.04; p=0.15). All outcomes demonstrated significant interaction p-values for beta-blocker efficacy according to baseline rhythm. The lack of efficacy for mortality was seen across all AF sub-groups. AF patients had more frequent CV-hospitalisation and longer length of stay (11.9 versus 9.7 days in sinus rhythm).ConclusionPatients with HF and concomitant AF have higher rates of death and hospitalisation. In contrast to the beneficial effects observed for those with sinus rhythm, beta-blocker therapy has no or minimal effect on mortality or cardiovascular hospitalisation in HF patients with reduced ejection fraction and AF. Our results dispute the preferential use of beta-blockers compared to other rate-control medications and highlight the need for further trials in this common and increasingly important group of patients.Registration: PROSPERO CRD42014010012; Clinicaltrials.gov NCT00832442.
By Lars Ryden, FESC (Stockholm, Sweden)See Presenter abstractOpen the presentationWatch the Webcast
Clinical Trial Update Hot Line: Stable CAD and atrial fibrillation
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