NEWS & VIEWS ATRIAL FIBRILLATION

Challenging the status quo: β‑blockers for HF plus AF Paul Khairy and Denis Roy

A new meta-analysis challenges the notion that β‑blockers improve survival in patients with heart failure (HF) and concomintant atrial fibrillation (AF). These results should be interpreted with caution. Although the mortality reduction conferred by β‑blockers was likely overestimated in the past, benefits should be expected in a sizeable proportion of patients with HF and AF. Khairy, P. & Roy, D. Nat. Rev. Cardiol. 11, 690–692 (2014); published online 14 October 2014; doi:10.1038/nrcardio.2014.166

Over the past 25  years, the survival of patients with heart failure (HF) and reduced ejection fraction (HFrEF) has been pro­ longed, owing to advances in both pharma­ cological and device therapy, including angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, β‑blockers, mineralocorticoid-receptor antagonists, implantable cardioverter–defibrillators, cardiac resynchronization therapy, and left ventricular assist devices. The randomized controlled trials in which the efficacy of these therapies was first demonstrated have shaped current guidelines on HF management.1 In some instances, however, data from subse­ quent observational studies have contested the purported benefits of the treatment in particular patient subgroups and raised con­ cerns over safety in the real-world setting.2,3 β‑Blockers were developed in the 1960s by the Nobel Prize recipient, James Black, and have since become a staple in the manage­ ment of HF.4 The benefits of β‑blockers have largely gone unchallenged, but a new metaanalysis published in The Lancet calls into question their efficacy in reducing mortality in the subgroup of patients with HFrEF and coexisting atrial fibrillation (AF).5 The Beta-Blockers in Heart Failure Collaborative Group analysed individual patient-level data from 10 major randomized clinical trials that compared β‑blockers to placebo for the treatment of HF.5 This multinational consortium was created to determine the efficacy of β‑blockers in understudied subgroups, including patients with concomitant AF. 5,6 As expected, β‑blocker administration was associated with

a significant reduction in both all-cause mor­ tality (HR 0.73, 95% CI 0.67–0.80, P 

Atrial fibrillation: Challenging the status quo: β-blockers for HF plus AF.

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