In patients with heart failure, is carvedilol better than metoprolol in decreasing mortality and improving quality of life?

Carvedilol (Coreg) treatment of patients with New York Heart Association (NYHA) functional class II-IV heart failure decreases mortality over 4 years more than metoprolol (number needed to treat = 18). Hospitalization rates, length of stay, and patient reports of symptoms are not different between the 2 drugs. (LOE = 1b)

Cleland JG, Charlesworth A, Lubsen J, et al, for the COMET Investigators. A comparison of the effects of carvedilol and metoprolol on well-being, morbidity, and mortality (the "patient journey") in patients with heart failure. J Am Coll Cardiol 2006;47:1603-1611.  [PMID:16630997]

Randomized controlled trial (double-blinded)

Industry + foundation

Uncertain

Outpatient (any)

The investigators enrolled 3029 patients who had NYHA class II-IV heart failure, an ejection fraction of 35% or less, and who were on stable treatment with an angiotensin-converting enzyme inhibitor and at least 40 mg/day of furosemide. The patients were randomly assigned to receive either carvedilol (Coreg) 25 mg or metoprolol 50 mg twice daily after a slow titration, which were then continued for an average for almost 5 years. On average, carvedilol decreased heart rate, a surrogate measure of beta-blockade, slightly more than metoprolol, although its effect probably is not related to changes in heart rate (Eur Heart J 2005;26:2259-2268). The investigators evaluated 4 outcomes using intention-to-treat analysis: death and hospitalization were the primary outcomes, and symptoms and well-being were secondary outcomes. Symptoms and well-being were measured by asking patients to indicate, on a scale of 1 to 5, the answer to the question, "Over the past week, how have you been feeling?" A score of 1 was coded as 100%, with each higher number resulting in assignment of a 20% decrement in well-being score (ie, a score of 3 would be scored as a 60%).The 4 outcomes were combined into a new outcome measure called "the patient journey," which is somewhat similar to quality-adjusted life-years. During the study period, there were fewer deaths in the patients assigned to carvedilol (number needed to treat = 18; 95% CI, 11-45). Hospitalization rates and length of stay did not differ between the 2 groups. Over the 4 years, the patient journey scores in both groups decreased as more patients died and as symptoms became worse. Patient journey scores were slightly better for the patients receiving carvedilol.