More Data on Beta-Blockers in Patients with Heart Failure and Atrial Fibrillation

New research indicates that atrial fibrillation (AF) eliminates the benefits that treatment with beta-blockers otherwise produces in patients with heart failure and reduced ejection fraction (HFrEF).

The authors of the meta-study note that current guidelines from both American and European authorities recommend beta-blockers for patients with heart failure and AF, but they believe their conclusions are strong enough to warrant changes.

“Based on our findings, beta-blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation,” they wrote in The Lancet.

The research team pulled individual patient data from 10 randomized controlled trials that compared beta-blockers against placebo for patients with HFrEF. All of those trials noted which patients had AF and provided data on all-cause mortality with at least six months of follow-up.

Together, the trials provided data for 13,946 patients with normal sinus rhythm and 3,066 patients with AF.

Analysis of subsequent patient deaths confirmed the benefits of beta-blockers for the first group of patients. After an average follow-up of 1.5 years, medication usage was associated with a 27% reduction in overall mortality as well as lower rates of both cardiovascular death and heart-related hospitalization.

For those with AF, however, beta-blockers were not associated with any significant benefit or harm, not for the group as a whole and not for any of the subgroups the researchers could make by dividing AF patients by age, sex, heart rate and other factors.

Lead author Dipak Kotecha, MD, who presented the paper at the European Society of Cardiology’s annual meeting in Barcelona, warned that the study findings may not apply to patients with good systolic function. Only 2% of the patients in the study had a left ventricular ejection fraction above 50%.

Another possible limitation of the study concerns the relative youth of the study patients. Those with normal sinus rhythm were 64 years old, on average and those with AF were 69 years old. The average age for all people who have HFrEF and AF is considerably older. Study ages typically skew young because many trials limit patient ages.

Still, the new research supports a handful of earlier studies that have found reason to question the benefit of beta-blockers for patients with both HFrEF and AF — studies that have left doctors wondering how best to control heart rate among such patients.

Guidelines warn against using diltiazem and verapamil on patients with heart failure and impaired systolic function because both drugs can mask symptoms that require attention. The use of digoxin has also come into question, thanks to new research that suggests it may harm patients with AF.

If further studies indicate that all the alternatives medications for rhythm control actually worsen outcomes, beta-blockers could remain the treatment of choice for reducing the discomfort associated with HFrEF and AF, even if they don’t improve outcomes at all.

Indeed, the guidelines from Britain’s National Institute for Health and Clinical Excellence came out after several studies that questioned the therapeutic benefit of beta-blockers for patients with both HFrEF and AF, but the guideline taskforce concluded that beta-blockers still appear to be the best available option.