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Alan S. Go, MD; Jingrong Yang, MA; Jerry H. Gurwitz, MD; John Hsu, MD, MBA, MSCE; Kimberly Lane, MPH; Richard Platt, MD, MSc

Arch Intern Med. 2008;168(22):2415-2421.

Background  Randomized trials have demonstrated the efficacy of selected β-blockers in systolic heart failure, but the comparative effectiveness of different β-blockers in practice is poorly understood.

Methods  We compared mortality associated with different β-blockers following hospitalization for heart failure between 2001 and 2003. Longitudinal exposure to β-blockers was ascertained from pharmacy databases. Patient characteristics and other medication use were identified from administrative, hospitalization, outpatient, and pharmacy databases. Death was identified from administrative, state mortality, and Social Security Administration databases. Multivariate Cox regression was used to examine the association between different β-blockers and death.

Results  Among 11 326 adults surviving a hospitalization for heart failure, 7976 received β-blockers (atenolol, 38.5%; metoprolol tartrate, 43.2%; carvedilol, 11.6%; and other, 6.7%) during follow-up. The rate (per 100 person-years) of death during the 12 months after discharge varied by exposure and type of β-blocker (atenolol, 20.1; metoprolol tartrate, 22.8; carvedilol, 17.7; and no β-blockers, 37.0). After adjustment for confounders and the propensity to receive carvedilol, the risk of death compared with atenolol was higher for metoprolol tartrate (adjusted hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.01-1.34) and no β-blockers (HR, 1.63; 95% CI, 1.44-1.84) but was not significantly different for carvedilol (HR, 1.16; 95% CI, 0.92-1.44).

Conclusions  Compared with atenolol, the adjusted risks of death were slightly higher with shorter-acting metoprolol tartrate but did not significantly differ for carvedilol in adults with heart failure. Our results should be interpreted cautiously and they suggest the need for randomized trials within real-world settings comparing a broader spectrum of β-blockers for heart failure.

Author Affiliations: Division of Research, Kaiser Permanente of Northern California, Oakland (Drs Go and Hsu and Ms Yang); Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco (Dr Go); Meyers Primary Care Institute, University of Massachusetts Medical School and Fallon Foundation, Worcester (Dr Gurwitz); Channing Laboratory, Brigham and Women's Hospital, and Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts (Ms Lane and Dr Platt); and Harvard Pilgrim Health Care, Boston (Ms Lane and Dr Platt).

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