The Pharmaceutical Journal
Vol 275 No 7366 p301
10 September 2005

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Beta-blockers can be used before ACE inhibitors in heart failure

Initiating treatment of chronic heart failure with a beta-blocker is as effective and as well-tolerated as starting treatment with an angiotensin-converting enzyme inhibitor, which is currently recommended in guidelines, according to the results of a new study presented at the European Society of Cardiology annual congress in Stockholm this week.

The Cardiac Insufficiency Bisoprolol Study (CIBIS III) randomised 1,010 patients with chronic heart failure to treatment with 1.25mg bisoprolol once daily or 2.5mg enalapril twice daily. The drugs were titrated upward every two weeks until the target maintenance dose of 10mg was reached. After a six-month monotherapy phase, the second drug was added.

Results after patients had been treated with combination therapy for 6–24 months showed similar rates of death and admission to hospital for both groups (hazard ratio 0.94; 95 per cent confidence interval 0.77–1.16).

The authors believe that initial use of a beta-blocker might be popular because many CHF patients have an abnormal heart rhythm, such as tachycardia. They suggested that there are also theoretical considerations as to why it might be beneficial to initiate treatment with a beta-blocker since beta-blockers inhibit both the sympathetic nervous system and the renin-angiotensin-aldosterone system. Also, sudden death is the most prevalent cause of mortality in the early course of CHF and this can be reduced with beta-blockers.

Steve McGlynn, specialist principal pharmacist for cardiology, NHS Greater Glasgow, said: “The study results show we have the option of starting patients on a beta-blocker first with no reduction in clinical benefit.” However, he noted that the study protocol of treating patients with monotherapy for six months before introducing the second drug was not part of clinical practice. He also warned that there may be difficulties in persuading GPs to start CHF patients on beta-blockers since they are currently given Quality and Outcome Framework points for patients on ACE inhibitors.