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Possible mechanisms of action in the positive effect of β blockers in heart failure
  1. M J Kendall
  1. Department of Clinical Pharmacology, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK
  1. Professor Kendall email:M.J.Kendall{at}

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Sudden death is very common in heart failure, and its occurrence is considerably underestimated. Data from the second cardiac insufficiency bisoprolol study (CIBIS II)1 and the metoprolol CR/XL randomised intervention trial in heart failure (MERIT-HF)2on total mortality, total cardiovascular mortality, sudden death, and heart failure, show clearly that sudden death is extremely common in patients with cardiovascular disease.

In the CIBIS II and MERIT-HF trials, 47% (fig 1) and 64% (fig 2) of people who died from a cardiovascular cause died suddenly. The risk of sudden death is particularly high in the most common type of patient with heart failure, those with New York Heart Association (NYHA) class II and III symptoms (fig 3).

Figure 1

Sudden death rate in the CIBIS II trial.1

Figure 2

Sudden death rate in the MERIT-HF trial.2

Figure 3

MERIT-HF: mode of death by NYHA class. Reproduced from Hjalmarson et al,2 with permission of The Lancet Ltd.

Preventing coronary events

In heart failure, the objective is to reduce symptoms and prolong life by making an impact on cardiac function, the underlying disease process, neurohumoral activation, and the risk of sudden death. …

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