Experience with beta-blocker therapy in patients with advanced heart failure evaluated for HTx

Background: The aim of this study was to review our experience with beta -b locker therapy on top of high-dose angiotensin-converting enzyme inhibitors (ACE-I) in patients with advanced heart failure evaluated for heart transp lantation, and to question the value of intended heart transplantation for patients receiving this therapy. Methods: Three hundred eighteen patients (New York Heart Association (NYHA) function class III 34%, class IV 66%, average left ventricular ejection fr action (LVEF) 16%, and average cardiac index 2.2 l/min per m(2) at time of referral) were treated with digitalis, loop diuretics, maximally uptitrated ACE-I, beta -blockers (if tolerated), and intravenous support (if needed). After 3 months, patients were retrospectively stratified into those receiv ing beta -blockers plus ACE-I (Group A, n = 126), ACE-I (Group B, n = 135), and ACE-I plus intravenous support (Group C, n = 57). Endpoint 1 of the st udy was combined urgent heart transplantation, mechanical assist device imp lantation, and pretransplant death during a follow-up of 12 to 48 (mean 19 +/- 11) months. Endpoint 2 was posttransplant mortality up to 48 (mean 14 /- 8) months. Results: In the pretransplantation period the survival rate was 58% and the mortality rate was 20%. Between Groups A and B there was a significant dif ference in mortality (9% vs 27%, p = 0.001) due to a lower sudden-death rat e in Group A (6% vs 17%, p < 0.01). While between Groups A and C all event rates of Endpoint 1 differed significantly, between Group C and Group B tot al mortality (30% vs 27%) was similar. However, in Group C urgent heart tra nsplantation (HTx) was more often performed than in Group B (54% vs 11%, p < 0.0001). Seventy of 318 patients (22%) underwent heart transplantation (1 6% urgent, 6% elective). Posttransplant actuarial survival of the entire tr ansplanted cohort (n = 70, 12 deaths) was significantly lower (log rank p < 0.01) than event-free survival in Group A (n = 126, 18 events), significan tly higher (log rank p < 0.0001) than event-free survival in Group C (n = 5 7, 34 events), and similar to that in Group B (n = 135, 52 events). Conclusion: This experience suggests that it may be particularly useful to add a beta -blocker to ACE-I therapy in patients referred for heart transpl antation. In patients who tolerate this treatment, heart transplantation do es not seem to provide additional survival benefit in the short term (2 yea rs).