B-CONVINCED: Continue Beta-Blockers in Acute HF

ACEP News
October 2009

Many physicians routinely halve the dose or halt the drug altogether.

By Bruce Jancin
Elsevier Global Medical News

BARCELONA -- The common practice of discontinuing beta-blocker therapy during hospitalization for an acute exacerbation of heart failure is counterproductive, according to a French randomized trial.

"During acute heart failure, beta-blocker therapy should be continued, because this practice is not associated with delayed or lesser improvement and there is a higher rate of chronic beta-blocker therapy 3 months later, the benefits of which are well established," Dr. Guillaume Jondeau concluded in presenting the results of the Beta Blocker Continuation Vs. Interruption in Patients With Congestive Heart Failure Hospitalized for a Decompensation Episode (B-CONVINCED) trial at the annual congress of the European Society of Cardiology.

B-CONVINCED was conducted to redress the lack of level 1 evidence regarding the best clinical strategy when patients with systolic dysfunction who are on chronic beta-blocker therapy are hospitalized for acute heart failure. Many physicians, reasoning that the acutely failing circulatory system needs adrenergic support, routinely halve the dose or halt the drug altogether. The 2008 ESC guidelines straddle the fence, stating as a class IIA recommendation that "a reduction in the beta-blocker dose may be necessary. In severe situations, temporary discontinuation can be considered."

B-CONVINCED was designed as a noninferiority trial. The study hypothesis was that continuing the beta-blocker would not result in worse outcomes than stoppage upon hospital admission.

The primary end point in the 147-patient multicenter trial was improvement in both dyspnea and general well-being as assessed by blinded physicians 3 days into the hospitalization. This was achieved in 93% of the beta-blocker continuation group and 92% of the drug-halt group. Similarly, another round of blinded physician assessments after 8 days concluded 95% of patients in both study arms were significantly improved. Duration of hospital stay, patient self-assessments, and rehospitalization rates during the next 3 months were also similar in the two groups.

However, the proportion of patients on beta-blocker therapy 3 months after the acute exacerbation was significantly different: 90% in the continuation group and 76% in the discontinuation group. This reflects the reality that once beta-blocker therapy for heart failure has been stopped, it can be a challenge to restart and titrate up to effective doses, said Dr. Jondeau of the University of Paris.

Discussant Karl Swedberg noted that there is a decades-long history of skepticism regarding the use of beta-blockers in heart failure. Yet today, beta-blockers are the best-documented and most effective therapy for systolic heart failure.

This trial provides the first solid randomized clinical trial evidence that sticking to the prehospitalization dose of a beta-blocker during an acute heart failure exacerbation instead of halting the drug at admission should be the first-line strategy, said Dr. Swedberg, professor of cardiology at Sahlgrenska University Hospital, Goteborg, Sweden.

"More patients will be on effective treatment at 3 months, and many lives will be saved by this strategy," he added.

B-CONVINCED was funded by the French Ministry of Health. Neither Dr. Jondeau nor Dr. Swedberg disclosed any relationships with industry.

 

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