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Title: A review of the external validity of clinical trials with beta-blockers in heart failure
Austin Authors: Iyngkaran, Pupalan;Toukhsati, Samia R ;Thomas, Merlin C;Jelinek, Michael V;Hare, David L ;Horowitz, John D
Affiliation: Northern Territory School of Medicine, Flinders University, Bedford Park, South Australia
Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia
Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
Department of Cardiology, St. Vincent's Hospital, Melbourne, Victoria, Australia
Cardiovascular Research, University of Melbourne, Melbourne, Victoria, Australia
Heart Failure Services, Austin Health, Heidelberg, Victoria, Australia
Cardiology Unit, Discipline of Medicine, Cardiology Research Laboratory, The Basil Hetzel Institute, Woodville South, South Australia, Australia
Issue Date: Oct-2016
Publication information: Clinical Medicine Insights: Cardiology 2016; 10: 163-171
Abstract: BACKGROUND: Beta-blockers (BBs) are the mainstay prognostic medication for all stages of chronic heart failure (CHF). There are many classes of BBs, each of which has varying levels of evidence to support its efficacy in CHF. However, most CHF patients have one or more comorbid conditions such as diabetes, renal impairment, and/or atrial fibrillation. Patient enrollment to randomized controlled trials (RCTs) often excludes those with certain comorbidities, particularly if the symptoms are severe. Consequently, the extent to which evidence drawn from RCTs is generalizable to CHF patients has not been well described. Clinical guidelines also underrepresent this point by providing generic advice for all patients. The aim of this review is to examine the evidence to support the use of BBs in CHF patients with common comorbid conditions. METHODS: We searched MEDLINE, PubMed, and the reference lists of reviews for RCTs, post hoc analyses, systematic reviews, and meta-analyses that report on use of BBs in CHF along with patient demographics and comorbidities. RESULTS: In total, 38 studies from 28 RCTs were identified, which provided data on six BBs against placebo or head to head with another BB agent in ischemic and nonischemic cardiomyopathies. Several studies explored BBs in older patients. Female patients and non-Caucasian race were underrepresented in trials. End points were cardiovascular hospitalization and mortality. Comorbid diabetes, renal impairment, or atrial fibrillation was detailed; however, no reference to disease spectrum or management goals as a focus could be seen in any of the studies. In this sense, enrollment may have limited more severe grades of these comorbidities. CONCLUSIONS: RCTs provide authoritative information for a spectrum of CHF presentations that support guidelines. RCTs may provide inadequate information for more heterogeneous CHF patient cohorts. Greater Phase IV research may be needed to fill this gap and inform guidelines for a more global patient population.
DOI: 10.4137/CMC.S38444
ORCID: 0000-0001-9554-6556
PubMed URL: 27773994
Type: Journal Article
Subjects: Beta-blockers
Chronic heart failure
External validity
Type of Clinical Study or Trial: Reviews/Systematic Reviews
Appears in Collections:Journal articles

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