Beta-blocker therapy in heart failure in the elderly

Chronic heart failure (CHF) is a common and disabling condition with morbidity and mortality that increase dramatically with advancing age. There is some evidence available about beta-blocker therapy in the elderly. The Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with Heart Failure (SENIORS) and retrospective subgroup (elderly) analyses of landmark clinical trials in stable systolic heart failure have provided data supporting the use of beta-blocker as baseline therapy in heart failure in the elderly. However, beta-blocker is still less frequently used in elderly compared to younger patients. There are many reasons, one of which is that available data on elderly patients are not as convincing as those pertaining to their younger counterparts. There is uncertainty or disagreement about whether beta-blockers are equally beneficial and well tolerated in elderly heart failure patients as in younger ones. In other words, the level of evidence regarding beta-blocker therapy in the elderly is not regarded as high as that in younger patients. Indeed, the senior heart failure population, which in fact comprises the majority of all heart failure patients, is in general less well studied, both experimentally and clinically, than younger populations. Both clinical studies and experience indicate good tolerability in the use of beta-blocker in the elderly. Although beta-blockers are well tolerated by the elderly, target doses (based on previous clinical trials) may be difficult to achieve. The question is whether we should use the same target dose in the elderly as that in younger patients. Theoretically, the most effective dose is the highest dose tolerated, which may differ across different age groups. Is it time to abandon the "target dose" for the "highest dose tolerated"? The time has come to carry out active research to achieve better documentation of evidence based heart failure management in the elderly for the benefit of a large number of elderly patients with heart failure. We need clinical trial data that show definite improvement in outcomes as well as a clear-cut, favourable benefit-risk analysis involving beta-blockers in typical older heart failure patients irrespective of comorbidity and polypharmacy. Until the above is available, it may be wiser to adhere to beta-blocker therapy, which at present is better documented than other heart failure therapies in the elderly. (C) 2007 Elsevier Ireland Ltd. All rights reserved.