Impact of Renal Impairment on Beta-Blocker Efficacy in PatientsWithHeartFailure

• Published in: Journal of the American College of Cardiology Vol. 74; no. 23; p. 2893
• Main Authors: Kotecha, Dipak, Gill, Simrat K, Flather, Marcus D, Holmes, Jane, Packer, Milton, Rosano, Giuseppe, Böhm, Michael, MacMurray, John J V, Wikstrand, John, Anker, Stefan D, van Veldhuisen, Dirk J, Manzano, Luis, von Lueder, Thomas G, Ridby, Alan S, Andersson, Bert, Kjekshus, John, Wedel, Hans, Ruschitzka, Frank, Cleland, John G F, Damman, Kevin, Redon, Josep, Coats, Andrew J S
• Format: Journal Article
• Language: English
• Published: 2019
• Subjects: Cardiac and Cardiovascular Systems; Kardiologi
• ISSN: 1558-3597
• DOI: 10.1016/j.jacc.2019.09.059

Moderate and moderately severe renal impairment are common in patients with heart failure and reduced ejection fraction, but whether beta-blockers are effective is unclear, leading to underuse of life-saving therapy.This study sought to investigate patient prognosis and the efficacy of beta-blockers according to renal function using estimated glomerular filtration rate (eGFR).Analysis of 16,740 individual patients with left ventricular ejection fraction<50% from 10 double-blind, placebo-controlled trials was performed. The authors report all-cause mortality on an intention-to-treat basis, adjusted for baseline covariates and stratified by heart rhythm.Median eGFR at baseline was 63 (interquartile range: 50 to 77) ml/min/1.73m2; 4,584 patients (27.4%) had eGFR 45 to 59ml/min/1.73m2, and 2,286 (13.7%) 30 to 44ml/min/1.73m2. Over a median follow-up of 1.3 years, eGFR was independently associated with mortality, with a 12% higher risk of death for every 10ml/min/1.73m2 lower eGFR (95% confidence interval [CI]: 10% to 15%; p<0.001). In 13,861 patients in sinus rhythm, beta-blockers reduced mortality versus placebo; adjusted hazard ratio (HR): 0.73 for eGFR 45 to 59ml/min/1.73m2 (95%CI: 0.62 to 0.86; p<0.001) and 0.71 for eGFR 30 to 44ml/min/1.73m2 (95%CI: 0.58 to 0.87; p=0.001). The authors observed no deterioration in renal function over time in patients with moderate or moderately severe renal impairment, no difference in adverse events comparing beta-blockers with placebo, and higher mortality in patients with worsening renal functionon follow-up. Due to exclusion criteria, there were insufficient patients with severe renal dysfunction (eGFR<30ml/min/1.73m2) to draw conclusions. In 2,879 patients with atrial fibrillation, there was no reduction in mortality with beta-blockers at any level of eGFR.Patients with heart failure, left ventricular ejection fraction<50% and sinus rhythm should receivebeta-blocker therapy even with moderate or moderately severe renal dysfunction.