The use of beta blockers for rate control in patients with atrial fibrillation (AF) and heart failure (HF) has shown mortality benefits. A study performed by Fauchier et al. found that there was a reduction of 40% with the use of beta blockers in patients that have AF and HF.1

Current recommendation of beta blockers in patient with HF include bisoprolol, carvediol, or metoprolol succinate. Metoprolol tartrate may provide better rate control with twice daily dosing.

Patients with AF that received carvedilol had an improvement in left ventricular end diastolic (p = <0.001), end-systolic dimensions (P = <0 .0001), and ejection fraction (P =<0 .0001) compared to patients who received metoprolol, which showed decreased end-systolic dimensions (P =0 .07), and increase in ejection fraction (P =0 .05). 2

The Carvedilol or Metoprolol European Trial (COMET)3, a randomized double blind trial, looked into the comparison of metoprolol tartrate and carvedilol in patients with HF. Carvedilol was shown to have  beneficial effects on mortality (RR 0.836: CI 0.74–0.94; P=0.0042).4 A prognostic relevance analysis of AF was performed on patients that were a part of COMET. Patients with HF were randomized to receive carvedilol or metoprolol tartrate. AF was associated with increased mortality (RR 1.29: 95% CI 1.12–1.48; P=<0.0001), and higher all cause death or hospitalization (RR 1.25: CI 1.13–1.38; P= <0.0001).4 The authors concluded that carvedilol, compared to metoprolol, offers additional benefits among patients with AF.4

A randomized trial performed by Fung J et al. compared the effectiveness of carvedilol and metoprolol tartratein patients with HF and AF.5 The study found that both treatment options had an equal improvement in left ventricular systolic function in HF with AF.5 These results were similar to those presented in other trials, such as the US Carvedilol Heart Failure Trials Program.

While there was no direct study regarding the use of metoprolol tartrate in a patient population involving HF and AF, many HF studies had a subgroup of patients who had concomitant AF that required assessment. One aspect of these studies to take into consideration would be the amount of patients that were assessed. A certain percentage of patients had HF and were in AF in many of the studies.

The overall conclusion is that the use of beta blocker therapy in patients with HF and AF has shown mortality benefit and would be recommended for use in management of patient’s care. Whether metoprolol tartrate would be preferred over carvedilol or other preferred beta blockers in patients with HF and AF, could not be determined.


REFERENCES
  1. Fauchier L, Grimard C, Pierre B et al. Comparison of Beta Blocker and Digoxin Alone and in Combination for Management of Patients With Atrial Fibrillation and Heart Failure. Am J Cardiol. 2009.
  2. Meng F, Yoshikawa T, Baba A et al. B-Blockers Are Effective in Congestive Heart Failure Patients With Atrial Fibrillation. J Card Fail. Vol. 9 No. 5 2003. doi:10.1054/S1071-9164(03)00127-1
  3. Poole- Wilson PA, Swedberg K, Cleland JG et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003 Jul 5;362(9377):7-13
  4. Swedberg, K, Olsson L, Charlesworth A et al. Prognostic relevance of atrial fibrillation in patients with chronic heart failure on long-term treatment with beta-blockers: results from COMET. Eur Heart J Issue: Volume 26(13), July 2005, pp 1303-1308. DOI: 10.1093/eurheartj/ehi166
  5. Fung J, Chan S, Yeung L, et al. Is beta-blockade useful in heart failure patients with atrial fibrillation? An analysis of data from two previously completed prospective trials. Eur J Heart Fail. 4 (2002). 489–494.