Comparative effectiveness of bisoprolol and metoprolol succinate in patients with heart failure

Role of Metoprolol Succinate in the Treatment of Heart Failure and Atrial Fibrillation: A Systematic Review

BACKGROUND

Beta-blockers are one of the most important classes of cardiovascular agents and have been considered a cornerstone therapy in heart diseases, such as heart failure (HF) and atrial fibrillation (AF). Among different beta-blockers, metoprolol is a selective beta1-adrenergic antagonist, which has been extensively used since the 1970s.

AREAS OF UNCERTAINTY

Although current guidelines include recommendations for the use of controlled-release metoprolol succinate in specific HF and AF indications, and despite extensive clinical experience with metoprolol, comparative evidence on the use of metoprolol succinate compared with other beta-blockers in these indications is limited.

DATA SOURCES

We systematically reviewed the data from head-to-head studies directly comparing this compound with other beta-blockers in the treatment of HF or AF. Only clinical trials and observational studies were considered; no other limits were applied. The quality and relevance of retrieved articles were reviewed.

RESULTS

A total of 18 articles of the 353 articles identified were selected for inclusion; 12 HF articles and 6 for AF. Additional references were identified from the bibliographies of retrieved articles. The studies show that oral prophylaxis with an appropriate dose of metoprolol may reduce new incidents of AF in high-risk patients. Furthermore, metoprolol succinate is associated with significant mortality and morbidity benefits in the treatment of HF.

CONCLUSIONS

Despite the introduction of newer beta-blockers with differing clinical characteristics since its introduction, metoprolol succinate remains a useful drug in both HF and AF.

Metoprolol in the treatment of cardiovascular disease: a critical reappraisal

BACKGROUND

Extensive clinical experience on metoprolol has been gained in different cardiovascular conditions.

REVIEW

This paper discusses the use of metoprolol, with a focus on the extended-release formulation, in clinical practice in the light of existing evidence and current recommendations. This is a narrative review based on existing evidence and clinical experience of the author. Evidence on the use of metoprolol in heart failure, ischemic artery disease, arterial hypertension, and atrial fibrillation is well-established.

CONCLUSIONS

Metoprolol still appears to be a suitable pharmacological option in different cardiovascular conditions. Research on this molecule is still active and new, promising settings of use are being explored and may provide relevant results in the years to come.

Epidemiology of heart failure in Germany: a retrospective database study

BACKGROUND

Chronic heart failure (HF) is associated with significant healthcare expenditure, morbidity, and mortality. This study investigated the epidemiology of HF in Germany.

METHODS

This retrospective study used anonymous healthcare claims data from the German Health Risk Institute on individuals with statutory health insurance. Patients with uninterrupted data from 1 January 2009 to 31 December 2013 or death (whichever occurred first), and ≥2 recorded HF-related diagnoses in 2011, were included. Patients with newly diagnosed HF were identified. Patients were followed up for 2 years from first diagnosis.

RESULTS

Of 3,132,337 eligible patients, 123,925 (55.0% women; mean age 76.2 years) had HF: a prevalence of 3.96%. Of these, 26,368 had newly diagnosed HF: an incidence of 655/100,000 persons at risk. Incidence increased with age and was similar regardless of sex. During follow-up, there were 48,159 hospital admissions among newly diagnosed patients (1.8 hospitalizations/patient/2 years); HF accounted for 6% of these. Additionally, 20,148 patients (16.3%) overall and 5983 newly diagnosed patients (22.7%) died. Most new cases of HF were diagnosed by office-based physicians (63.2%); new cases among hospital inpatients were predominantly diagnosed by internal medicine specialists (70.7%). Overall, 94.0% received their initial prescription for HF treatment from a family practitioner.

CONCLUSIONS

The high prevalence and incidence observed in this representative sample emphasize the burden of HF in Germany. Substantial hospitalization rates and mortality highlight the need for early diagnosis and appropriate treatment, and for close cooperation between physician specialties and healthcare sectors.

Bisoprolol compared with carvedilol and metoprolol succinate in the treatment of patients with chronic heart failure

AIMS

Beta-blockers are recommended for the treatment of chronic heart failure (CHF). However, it is disputed whether beta-blockers exert a class effect or whether there are differences in efficacy between agents.

METHODS AND RESULTS

6010 out-patients with stable CHF and a reduced left ventricular ejection fraction prescribed either bisoprolol, carvedilol or metoprolol succinate were identified from three registries in Norway, England, and Germany. In three separate matching procedures, patients were individually matched with respect to both dose equivalents and the respective propensity scores for beta-blocker treatment. During a follow-up of 26,963 patient-years, 302 (29.5%), 637 (37.0%), and 1232 (37.7%) patients died amongst those prescribed bisoprolol, carvedilol, and metoprolol, respectively. In univariable analysis of the general sample, bisoprolol and carvedilol were both associated with lower mortality as compared with metoprolol succinate (HR 0.80, 95% CI 0.71-0.91, p < 0.01, and HR 0.86, 95% CI 0.78-0.94, p < 0.01, respectively). Patients prescribed bisoprolol or carvedilol had similar mortality (HR 0.94, 95% CI 0.82-1.08, p = 0.37). However, there was no significant association between beta-blocker choice and all-cause mortality in any of the matched samples (HR 0.90; 95% CI 0.76-1.06; p = 0.20; HR 1.10, 95% CI 0.93-1.31, p = 0.24; and HR 1.08, 95% CI 0.95-1.22, p = 0.26 for bisoprolol vs. carvedilol, bisoprolol vs. metoprolol succinate, and carvedilol vs. metoprolol succinate, respectively). Results were confirmed in a number of important subgroups.

CONCLUSION

Our results suggest that the three beta-blockers investigated have similar effects on mortality amongst patients with CHF.

The Danish Heart Failure Registry

Aim of database

The aim of the Danish Heart Failure Registry (DHFR) is to monitor and improve the care of patients with incident heart failure (HF) in Denmark.

Study population

The DHFR includes inpatients and outpatients (≥18 years) with incident HF. Reporting to the DHFR is mandatory for the Danish hospital departments treating patients with incident HF. Final decision to register a patient in the DHFR is made by a cardiologist to ensure the validity of the diagnosis. Approximately 42,400 patients with incident HF were registered in the DHFR in July 2015.

Main variables and descriptive data

The main variables recorded in the DHFR are related to the indicators for quality of care in patients with incident HF: performance of echocardiography, functional capacity (New York Heart Association functional classification), pharmacological therapy (angiotensin converting enzyme/angiotensin II antagonist inhibitors, beta-blockers, and mineralocorticoid receptor antagonist), nonpharmacological therapy (physical training, patient education), 4-week readmission rate, and 1-year mortality. Furthermore, basic patient characteristics and prognostic factors (eg, smoking and alcohol) are recorded. At the annual national audit in the DHFR, the indicators and standards for good clinical quality of care for patients with HF are discussed, and recommendations are reported back to clinicians to promote quality improvement initiatives. Furthermore, results and recommendations are communicated to the public in an annual report. All standards for the quality indicators have been met at a national level since 2014. Indicators for treatment status 1 year after diagnosis are under consideration (now prevalent HF).

Conclusion

The DHFR is a valuable tool for continuous improvement of quality of care in patients with incident HF in Denmark. Furthermore, it is an important resource for the Danish registry-based HF research.

Effects of bisoprolol in combination with trimetazidine on the treatment of heart failure and concomitant chronic obstructive pulmonary disease

Objective:

To evaluate the effects of bisoprolol combined with trimetazidine on the treatment of heart failure patients having concomitant chronic obstructive pulmonary disease (COPD); in comparison with control group treated with standard therapy only.

Methods:

A total of 120 heart failure patients having concomitant COPD were selected and randomly divided into a control group and a treatment group according to different treatment methods (n=60). The control group was given continuous low flow oxygen inhalation and inotropic agents, and their cardiac stress was also reduced. The treatment group was treated with bisoprolol fumarate and trimetazidine in addition to treatment for COPD. For all patients, blood gas analysis and parameters reflecting cardiac function were measured respectively before and after treatment. The respiratory symptoms (cough, sputum, polypnea, gasp, dyspnea), limitation of motion (daily life, household duties, entertainment, sports), disease impacts (social contact, emotion, anxiety) and St. George’s Respiratory Questionnaire (SGRQ) total scores were observed using SGRQ.

Results:

The oxygen partial pressure (PaO₂) and partial pressure of carbon dioxide (PaCO₂) of the treatment group after treatment were significantly different from those before treatment. After treatment, peak E, E/A and IVEF were increased by 41%, 44% and 16% respectively, but peak A, LVPWT/mm and IVST/mm were significantly reduced. The differences in the respiratory symptoms, limitation of motion, disease impacts and SGRQ total scores were statistically significant compared with those before treatment (P<0.05) and those of the control group (P<0.05).

Conclusion:

Combining bisoprolol with trimetazidine in the treatment of heart failure complicating COPD can effectively improve blood gas indices, left ventricular systolic and diastolic functions and the quality of life, thereby alleviating clinical symptoms.