engleski

Beta-blockers in heart failure: benefits in elderly and patients with comorbidities

World population is aging and according to United Nations future projections such trend will continue. Heart failure (HF) is also growing, and is doing so mainly in the elderly population, with a mean age of such patients being now around 74 years. The leading etiology of HF in Europe in patients under 75 years is a coronary heart disease, frequently with previous myocardial infarction and subsequent left ventricular (LV) systolic dysfunction. In the elderly, other mechanism are often present, such as systolic hypertension with LV hypertrophy, apoptosis and fibrosis, being responsible for the important component of diastolic LV dysfunction. Therefore, in elderly patients not only the neuroendocrine constellation, but the myocardial structural and functional substrate of HF is different. A holistic approach to the patient is crucial and HF should never be the only diagnosis. A proper diagnostic formulation must extend beyond HF per se to hypertension and peripheral vascular disease, and also beyond cardiovascular system to diabetes and possible lung or kidney disease. This is very important particularly in the elderly in whom multiple rather than single diseases are common, influencing the optimal choice of treatment. According to benefits of beta-blockade in HF, shown in several major trials (CIBIS II, US Carvedilol Programme, COPERNICUS, MERIT-HF, SENIORS, CAPRICORN, COMET), actual ESC guidelines are recommending four beta-blockers in the treatment of HF: bisoprolol, carvedilol, metoprolol succinate and nebivolol (level of evidence A, class of recommendation I). Underusage of beta-blockers in high risk patients is a serious problem, especially in elderly, diabetic and most serious NYHA class III-IV patients. The main reasons for such underusage are complexity in drug initation and uptitration, risk of intolerance and/or worsening of HF and delay in beneficial effects on outcomes. Should beta-blockers be used in the elderly and patients with comorbidities? The answer to such question is positive, based on the results of several HF trials, clearly showing beneficial effects in high risk patients, with significant reduction in morbidity and mortality. Beta-blockers differ in their pharmacological properites. In the optimal selection of a drug for the individual patient, it is not appropriate to compare different trials, but to match the patient with the trial and individualize treatment based on patients clinical characteristics. In the elderly, beta-blockers are effective in most patients with LV systolic dysfunction, are well tolerated in at least 2/3 of patients, should be started and slowly titrated to at least ≥50% of the target dose, and should be carefully monitored at least for the first 1-3 months. Unfortunately, in everyday practice patients with HF at greatest risk of death are least likely to receive most effective treatment, ACE inhibitors or ARBs, and beta-blockers. Understanding the reasons underlying this mismatch may facilitate improvements in care and outcomes for patients with HF.

beta-blockers; heart failure; treatment; elderly

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