β-Blockers in Congestive Heart Failure: A Bayesian Meta-Analysis

Abstract

Purpose: Congestive heart failure is an important cause of patient morbidity and mortality. Although several randomized clinical trials have compared ␤-blockers with placebo for treatment of congestive heart failure, a meta-analysis quantifying the effect on mortality and morbidity has not been performed recently. Data Extraction: A specified protocol was followed to extract data on patient characteristics, ␤-blocker used, overall mortality, hospitalizations for congestive heart failure, and study quality.Data Synthesis: A hierarchical random-effects model was used to synthesize the results. A total of 22 trials involving 10 135 patients were identified. There were 624 deaths among 4862 patients randomly assigned to placebo and 444 deaths among 5273 patients assigned to ␤-blocker therapy. In these groups, 754 and 540 patients, respectively, required hospitalization for congestive heart failure. The probability that ␤-blocker therapy reduced total mortality and hospitalizations for congestive heart failure was almost 100%. The best estimates of these advantages are 3.8 lives saved and 4 fewer hospitalizations per 100 patients treated in the first year after therapy. The probability that these benefits are clinically significant (>2 lives saved or >2 fewer hospitalizations per 100 patients treated) is 99%. Both selective and nonselective agents produced these salutary effects. The results are robust to any reasonable publication bias.Conclusions: ␤-Blocker therapy is associated with clinically meaningful reductions in mortality and morbidity in patients with stable congestive heart failure and should be routinely offered to all patients similar to those included in trials. Ann Intern Med. 2001;134:550-560. www.annals.org For author affiliations, current addresses, and contributions, see end of text.C ongestive heart failure has reached pan-epidemic proportions in industrialized countries and is responsible for vast patient morbidity and mortality (1-4). Mortality associated with moderate to severe congestive heart failure may exceed that associated with many neoplasms, and the 1-year survival rate is as dismal as 50% (5). Quality of life is also adversely affected, and congestive heart failure is the most common cause of hospital admission in elderly persons in North America (6). Clearly, additional therapies are urgently needed.Randomized clinical trials are the gold standard for comparative research and have been used to investigate both new and old therapies for congestive heart failure. For example, trials have clearly demonstrated the beneficial effect of angiotensin-converting enzyme inhibitors on patient mortality (7), the neutral effect of digitalis (8), and the deleterious effects of other inotropic agents in congestive heart failure (9 -11).Although conventional medical education previously viewed congestive heart failure as a contraindication for the use of ␤-blockers because of their potential short-term negative inotropic effects, benefits of ␤-blocker treatment in this condition have been sporadica...

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