Alpha Blockers and Heart Failure
Alpha Blockers and Heart Failure
Abstract & Commentary
By Michael H. Crawford, MD
Source: Dhaliwal AS, et al. Impact of alpha 1-adrenergic antagonist use for benign prostatic hypertrophy on outcomes in patients with heart failure. AJC. 2009;104:270-275.
Based upon an increased incidence of heart failure with alpha 1-adrenergic antagonists treatment of hypertension, there has been concern about using alpha blockers for benign prostatic hypertrophy (BPH) in patients with heart failure, yet these drugs are highly efficacious for this common condition. Thus, Dhaliwal et al from the Veterans Affairs Medical Center in Houston, Texas, used an existing database of 386 men admitted for decompensated heart failure to study this issue. The primary endpoints were mortality and first rehospitalization for heart failure, alone or in combination. The patients were categorized as being on alpha 1 blockers (n = 98) or not (n = 290) at discharge, and subgrouped into those taking beta blockers or not. Carvedilol was considered a beta blocker for this analysis.
Results: Alpha-blocker therapy was not associated with an increase in the primary endpoints (HR 1.24, CI 0.93-1.65, p = 0.14) unless the patients were not on concomitant beta-blocker therapy (1.94,1.14-3.32, p = 0.015) over a one-year average follow-up. The patients on alpha blockers were older (73 vs. 67 years, p < 0.001) and had a higher left-ventricular ejection fraction (EF) (28 vs. 25%, p = .05). Also, more of those on alpha blockers were in the preserved (> 45%) EF group (21 vs. 10%, p = 0.005). Dhaliwal et al concluded that baseline beta-blocker therapy prevented any harmful effects of alpha blockers in patients with heart failure.
Commentary
Although this is a small, retrospective, observational study, it does provide reassurance that patients on modern multi-neurohormonal blockade for heart failure do not experience adverse effects from concomitant alpha 1 adrenergic blockade therapy for BPH. In this all-male cohort, alpha-blocker therapy was common (25%), and the agents used were those typically used for BPH. Prior studies of heart-failure and hypertensive patients have shown an increased incidence of fluid retention and heart failure exacerbation with alpha 1 blockade therapy, despite reductions in blood pressure. These prior studies did not involve baseline therapy with renin-angiotensin-aldosterone system antagonists or beta blockers. In this study, most were on this background therapy, and beta blockers seemed to be key, since their absence was associated with more readmissions for heart failure but not higher mortality. This makes sense, since it is believed that isolated alpha 1 blockade leads to reflex beta 1 stimulation and increased renin and aldosterone production. The net result would be fluid retention and possible heart failure exacerbation. Thus, it would seem that alpha 1 blockade should be used cautiously in heart-failure patients not on beta blockers.
The relative safety of alpha 1 blockers in these patients admitted for heart failure on modern therapy is important because of the potential therapeutic uses of these agents. They are effective agents for BPH symptoms and hypertension, and they raise HDL cholesterol levels.
Based upon an increased incidence of heart failure with alpha 1-adrenergic antagonists treatment of hypertension, there has been concern about using alpha blockers for benign prostatic hypertrophy (BPH) in patients with heart failure, yet these drugs are highly efficacious for this common condition.Subscribe Now for Access
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