Optimising the use of beta-blockers in older patients with heart failure.

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.