Introducing new treatments in clinical practice: the Italian approach to β blockers in heart failure

Congestive heart failure (CHF) is a growing public health problem, having a significant impact on the health care system.1-3 Recently β adrenergic antagonists, considered in the past a potential cause of worsening heart failure, have emerged as a promising approach in the treatment of patients with CHF, reducing sympathetic activity and its deleterious consequences.4 Several randomised clinical trials have tested the effects of carvedilol, metoprolol, and bisoprolol in patients with heart failure with different causes and severity. The results of these trials have shown that β blockers can have a favourable role in improving left ventricular function, reducing symptoms and the need for hospitalisation, delaying clinical progression of the disease, and, as a logical consequence, reducing mortality.5-8 However, clinical experience shows that treatment with β blockers is delicate to manage and potentially harmful in inexperienced hands. A short epidemiological study conducted in Italy in 1994 showed that β blockers were used in only 4% of Italian patients with heart failure, acknowledging that most Italian cardiologists were inexperienced in this field.9 With such background the Italian Association of Hospital Cardiologists (ANMCO) adopted three different lines of intervention: