Treatment of early heart failure: an ACEI or a beta-blocker first?
The basis of modern chronic heart failure (CHF) treatment is a combination of optimum doses of a beta-blocker and an angiotensin-converting enzyme inhibitor (ACEI); however, patients cannot be started on full doses of both drugs and treatment has to be initiated one way or the other. By tradition and according to guideline recommendations, an ACEI is usually initiated first, followed by a beta-blocker after a varying time period based on clinical judgement. Early beta-blockade has several theoretical advantages, and two surrogate end point studies have indicated that initiation of CHF treatment with a beta-blocker may be superior to an ACEI. The Cardiac Insufficiency Bisoprolol III trial was the first trial investigating the optimum sequence of initiating treatment of CHF in terms of mortality and morbidity. The results indicated that, in stable, mildly to moderately symptomatic patients with systolic CHF, initiation of therapy with the beta-blocker bisoprolol followed by the ACEI enalapril was similarly efficacious to the opposite sequence in terms of combined mortality and all-cause hospitalisation. However, initiating therapy with bisoprolol showed a trend towards better survival, but also towards further worsening of CHF. This review aims to put these recent findings into clinical perspective.
Willenheimer
Ronnie
R
Lund University, Department of Clinical Sciences, Malmö, Sweden. ronnie.willenheimer@med.lu.se
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D006333:Heart Failure / Q000188:drug therapy* / Q000378:metabolism; D006801:Humans
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors