Beta Blockers in childhood heart failure: Do pediatric cardiologists have reliable data to decline a potentially lifesaving therapy?

Today in cardiology the efficacy of beta blockers in patients with congestive heart failure is beyond all doubt. Beta blockers, as a class, provide mortality benefits in comparison with placebo or standard treatment in patients with mild to severe heart failure. Based upon the disappointing results of the two biggest US studies in children with heart failure beta blockers as well as ACE inhibitors seem to be ineffective. However, looking at the details researchers found the greatest benefit of beta blockers in patients with the most severe heart failure. Therefore, the US-Carvedilol trial in children is clearly underpowered. This trial recruited only children with mild heart failure indicated by very low mean BNP levels (110pg/ml). In the CHF-Pro-Infant trial in infants with congenital heart disease with severe heart failure and high neurohormonal activity we showed significant beneficial effects on Ross Score and neurohormonal activity. Our results are now confirmed by the prospective randomized trial VSD-PHF in 80 infants with VSD from India. Propranolol is the only drug that was successful in prospective randomized trials in infants with congenital heart disease (N=100). Today mortality due to heart failure in infants with congenital heart disease remains a dangerous problem. Sommers et al in 2005 showed that 111 of 1755 unselected children with heart disease died within 10 years, 67% within the first year of life.

Despite high level surgery the cause of death was heart failure in 74%. We respectfully submit that there is significant evidence to support the use of beta blockers in children with heart failure, and to withhold this potentially lifesaving therapy based on underpowered negative studies is unwarranted.