Kent and Canterbury Hospital,
Canterbury, UK.
Heart failure is predominantly a
disease of the older person with half of all patients
with the condition aged >75 years. Diuretics are
the first-line symptomatic treatment for heart failure.
beta-blockers should be initiated on an outpatient
basis once the patient is stable, euvolaemic (by means
of a diuretic) and established on an angiotensin converting
enzyme (ACE) inhibitor. Large trials have demonstrated
the beneficial effects of the beta-blockers carvedilol,
Metoprolol and bisoprolol in patients with heart failure,
most of whom were also receiving ACE inhibitors. However,
the mean age of patients in these trials was generally
60 to 65 years, with very few patients aged >75
years being recruited. It is, thus, not immediately
clear how to apply these trial results to older patients
with heart failure. Subgroup analyses from these large
beta-blocker heart failure trials suggest that older
patients gain similar benefit from beta-blocker treatment
to younger patients. The trials, however, give no
guidance as to whether older patients should receive
the same target dosage or titration regimen as younger
patients. It is suggested that a less aggressive titration
regimen may be more appropriate for older patients
while still attempting to achieve the trial target
dosages. Titration can be safely achieved on an outpatient
basis. In particular, a period of observation in the
clinic after initiation of treatment does not appear
to be necessary. The survival benefit resulting from
the use of a beta-blocker in patients with heart failure
is modest (months rather than years). It is, thus
important not to neglect the effects of treatment
on quality of life. A proportion of patients experience
adverse effects with a beta-blocker. For such patients
a balance needs to be made between the adverse effects
on quality of life and the likely extension of life
from the use of a beta-blocker. For patients who can
tolerate a beta-blocker, the available evidence suggests
that it can improve quality of life. The evidence
currently available does not support the use of an
angiotensin II receptor blocker (ARB) in addition
to an ACE inhibitor and beta-blocker. For patients
unable to tolerate an ACE inhibitor or beta-blocker,
the use of an ARB may confer some advantage.
