title: Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET.
abstract: BACKGROUND
  It is unclear whether beta-blocker therapy should be reduced or withdrawn in patients who develop acute decompensated heart failure (HF). We studied the relationship between changes in beta-blocker dose and outcome in patients surviving a HF hospitalisation in COMET.
  
  
  METHODS
  Patients hospitalised for HF were subdivided on the basis of the beta-blocker dose administered at the visit following hospitalisation, compared to that administered before.
  
  
  RESULTS
  In COMET, 752/3029 patients (25%, 361 carvedilol and 391 metoprolol) had a non-fatal HF hospitalisation while on study treatment. Of these, 61 patients (8%) had beta-blocker treatment withdrawn, 162 (22%) had a dose reduction and 529 (70%) were maintained on the same dose. One-and two-year cumulative mortality rates were 28.7% and 44.6% for patients withdrawn from study medication, 37.4% and 51.4% for those with a reduced dosage (n.s.) and 19.1% and 32.5% for those maintained on the same dose (HR,1.59; 95%CI, 1.28-1.98; p<0.001, compared to the others). The result remained significant in a multivariable model: (HR, 1.30; 95%CI, 1.02-1.66; p=0.0318). No interaction with the beneficial effects of carvedilol, compared to metoprolol, on outcome was observed (p=0.8436).
  
  
  CONCLUSIONS
  HF hospitalisations are associated with a high subsequent mortality. The risk of death is higher in patients who discontinue beta-blocker therapy or have their dose reduced. The increase in mortality is only partially explained by the worse prognostic profile of these patients.
authors.affiliation: Section of Cardiovascular diseases, Department of Experimental and Applied Medicine, University of Brescia, Italy. metramarco@libero.it
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.forename: Christian
authors.initials: C
authors.lastname: Torp-Pedersen
authors.forename: John G F
authors.initials: JG
authors.lastname: Cleland
authors.forename: Andrea
authors.initials: A
authors.lastname: Di Lenarda
authors.forename: Michel
authors.initials: M
authors.lastname: Komajda
authors.forename: Willem J
authors.initials: WJ
authors.lastname: Remme
authors.forename: Livio
authors.initials: L
authors.lastname: Dei Cas
authors.forename: Philip
authors.initials: P
authors.lastname: Spark
authors.forename: Karl
authors.initials: K
authors.lastname: Swedberg
authors.forename: Philip A
authors.initials: PA
authors.lastname: Poole-Wilson
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage*; D000368:Aged; D002227:Carbazoles / Q000008:administration & dosage*; D000077261:Carvedilol; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008790:Metoprolol / Q000008:administration & dosage*; D008875:Middle Aged; D011379:Prognosis; D011412:Propanolamines / Q000008:administration & dosage*; D028761:Withholding Treatment
chemical_list: D000319:Adrenergic beta-Antagonists; D002227:Carbazoles; D011412:Propanolamines; D000077261:Carvedilol; D008790:Metoprolol