Recent meta-analysis published in The Lancet showed that beta-blockers have no benefit in HF patients with AF. In addition, recent studies show that digoxin could be linked to increased mortality. Are we losing two main drugs in HF treatment in AF patients? What are your views on this controversy?
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61373-8/abstract
http://eurheartj.oxfordjournals.org/content/early/2012/11/14/eurheartj.ehs348.full
The results of both studies are fascinating and seem to raise the questions of using BB or digoxin in HF treatment in AF patients is to be considered unsafe.
The evidence related to the potential hazard of using digoxin in AF is growing. Also recently published TREAT-AF study, based on more than 122 000 patients (J Am Coll Cardiol 2014; 64:660–668) found significant increase in mortality in patients with AF independent of HF. In my opinion, the place of digoxin in our daily practice should be minimized to the minimum.
The results of meta-analysis of BB published in Lancet are somewhat surprising. However, meta-analysis study should be interpreted with caution as the type and the dose of BB were not analysed. The authors of this study found no evidence that β-blocker therapy prevents adverse clinical events in patients with heart failure and atrial fibrillation; it did seem to be safe with no increase in mortality or hospital admission rates. Therefore, I believe additional studies are needed to find out which dose/type of BB is safe/unsafe. According to my opinion, only this study will not change clinical practice.
Dear David,
"Based on our findings, beta-blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation," Kotecha and colleagues conclude.
Terrible (and astonishing): firstly, we can't use digoxin, and we all know why. Secondly, we can't use verapamil or diltiazem, and we know why even better. Third, are we killing anyone with bisoprolol in the HFrEF setting and AFib? This is not the case.
Just to enjoy some science-fiction, there is evidence that pulmonary vein ablation in conjunction with CRT are more effective than "pharmacological ablate" and pace for these HF patients, but in my practice I saw only one patient who was treated in this fashion.
Let's talk about it...
the results of this meta-analisis of betablockers on atrial fibrillation in HF must be taken with caution. It seems necesary to develop prospective/RCT to determine its long term utility in this setting
I totally agree with your observation regarding taking caution because it would seem highly unlikely that the same drug lowers mortality in so many trials and HF patients and on the other hand would not in HF + AF. The only explanation (although hard to comprehend) would be that AF and HF are two very different pathologies?
Let us summarise the previous comments on HF treatment with AF:
Do not use digoxin, be very, very careful with CACB in the setting of HF. Ivabradine obviously is not an option.
The consequence of all this is that you will have to use a beta blocking drug for controlling heart rate. The meta-analysis tells you very clearly that the use of beta blocking drugs is not associated with more side effects or poorer outcome. This already is very good news.
The lack of beneficial effect is fascinating, hypothesis generating but remains a post hoc analysis.
So, no reason to modify guidelines nor clinical practice at this time.
I somehow do not really understand the issue. From the randomized / controlled DIG study series we have learnt that Digitalis is prognostically neutral and symptomatically beneficial. What has changed since then ? Is there anything more influential than a properly designed RCT ? All these recent messages are at best question or hypothesis generating, thus perhaps the DIG studies should be replicated in a modern CRT/ICD-carrying HFrEF-population. Until then there is no reason for me to change practice.