© 2007 European Society of Cardiology
Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET
a Section of Cardiovascular diseases; Department of Experimental and Applied Medicine, University of Brescia Italy
b Department of Cardiology, Bispebjerg University Hospital Copenhagen, Denmark
c Department of Cardiology, University of Hull Kingston upon Hull, UK
d Department of Cardiology, Ospedale di Cattinara Trieste, Italy
e Department of Cardiology, La Pitié-Salpétrière Hospital Paris, France
f Sticares Cardiovascular Research Foundation Rhoon, The Netherlands
g Nottingham Clinical Research Group Nottingham, UK
h Department of Emergency and Cardiovascular Medicine, Sahlgrenska Academy, Göteborg University Göteborg, Sweden
i National Heart and Lung Institute, Imperial College London UK
* Corresponding author. Cattedra di Cardiologia, c/o Spedali Civili, P.zza Spedali Civili, 25123 Brescia, Italy. Tel.: +39 030 3995572; fax: +39 030 3700359. E-mail address: metramarco{at}libero.it
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Abstract |
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Background: It is unclear whether beta-blocker therapy should be reduced or withdrawn in patients who develop acute decompensated heart failure (HF). We studied the relationship between changes in beta-blocker dose and outcome in patients surviving a HF hospitalisation in COMET.
Methods: Patients hospitalised for HF were subdivided on the basis of the beta-blocker dose administered at the visit following hospitalisation, compared to that administered before.
Results: In COMET, 752/3029 patients (25%, 361 carvedilol and 391 metoprolol) had a non-fatal HF hospitalisation while on study treatment. Of these, 61 patients (8%) had beta-blocker treatment withdrawn, 162 (22%) had a dose reduction and 529 (70%) were maintained on the same dose. One-and two-year cumulative mortality rates were 28.7% and 44.6% for patients withdrawn from study medication, 37.4% and 51.4% for those with a reduced dosage (n.s.) and 19.1% and 32.5% for those maintained on the same dose (HR,1.59; 95%CI, 1.28–1.98; p<0.001, compared to the others). The result remained significant in a multivariable model: (HR, 1.30; 95%CI, 1.02–1.66; p=0.0318). No interaction with the beneficial effects of carvedilol, compared to metoprolol, on outcome was observed (p=0.8436).
Conclusions: HF hospitalisations are associated with a high subsequent mortality. The risk of death is higher in patients who discontinue beta-blocker therapy or have their dose reduced. The increase in mortality is only partially explained by the worse prognostic profile of these patients.
Key Words: Decompensated heart failure • Trials • Beta-blockers
Received December 30, 2005; Revised February 4, 2007; Accepted May 16, 2007
Source of funding: COMET was supported by F Hoffmann La Roche and GlaxoSmithKline.
1 The COMET investigators are listed in a previous paper (1).
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