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IMPORTANCE Heart failure with preserved ejection fraction (HFPEF)may be as common and may have similar mortality as heart failure with reduced ejection fraction (HFREF). β-Blockers reduce mortality in HFREF but are inadequately studied in HFPEF. OBJECTIVE To test the hypothesis that β-blockers are associated with reduced all-cause mortality in HFPEF. DESIGN Propensity score--matched cohort study using the Swedish Heart Failure Registry. Propensity scores for β-blocker use were derived from 52 baseline clinical and socioeconomic variables. SETTING Nationwide registry of 67 hospitals with inpatient and outpatient units and 95 outpatient primary care clinics in Sweden with patients entered into the registry between July 1, 2005, and December 30, 2012, and followed up until December 31, 2012. PARTICIPANTS From a consecutive sample of 41 976 patients, 19 083 patients with HFPEF (mean [SD] age, 76 [12] years; 46%women). Of these, 8244 were matched 2:1 based on age and propensity score for β-blocker use, yielding 5496 treated and 2748 untreated patients with HFPEF. Also we conducted a positive-control consistency analysis involving 22 893 patients with HFREF, of whom 6081 were matched yielding 4054 treated and 2027 untreated patients. EXPOSURES β-Blockers prescribed at discharge from the hospital or during an outpatient visit, analyzed 2 ways: without consideration of crossover and per-protocol analysis with censoring at crossover, if applicable. MAIN OUTCOMES AND MEASURES The prespecified primary outcomewas all-cause mortality and the secondary outcome was combined all-cause mortality or heart failure hospitalization. RESULTS Median follow-up in HFPEF was 755 days, overall; 709 days in the matched cohort; no patients were lost to follow-up. In the matched HFPEF cohort, 1-year survival was 80% vs 79% for treated vs untreated patients, and 5-year survival was 45%vs 42%, with 2279 (41%) vs 1244 (45%) total deaths and 177 vs 191 deaths per 1000 patient-years (hazard ratio [HR], 0.93; 95%CI, 0.86-0.996; P = .04). β-Blockers were not associated with reduced combined mortality or heart failure hospitalizations: 3368 (61%) vs 1753 (64%) total for first events, with 371 vs 378 first events per 1000 patient-years (HR, 0.98; 95%CI, 0.92-1.04; P = .46). In the matched HFREF cohort, β-blockers were associated with reduced mortality (HR, 0.89; 95%CI, 0.82-0.97, P=.005) and also with reduced combined mortality or heart failure hospitalization (HR, 0.89; 95%CI, 0.84-0.95; P = .001). CONCLUSIONS AND RELEVANCE In patients with HFPEF, use of β-blockers was associated with lower all-cause mortality but not with combined all-cause mortality or heart failure hospitalization. β-Blockers in HFPEF should be examined in a large randomized clinical trial. [ABSTRACT FROM AUTHOR]

Several letters to the editor and a reply from authors are presented in response to the article "Aldosterone Inhibition in Patients With Heart Failure With Preserved Ejection Fraction" by Edelmann F and colleagues in previous issue.

The article offers information on a study based on reducing mortality in population with heart failure with preserved ejection fraction (HFPEF) by the use of renin-angiotensin system [RAS] antagonists. It further mentions of HFPEF with its comparison to the lethality of the heart failure with reduced ejection fraction. It says that Swedish Heart Failure Registry with patients registered from hospitals and outpatient clinics from the year 2000 to 2011was included in the study. It concludes that RAS antagonists are associated in lowering all-cause mortality in the subjects.

The article focuses on a study which assessed the effectiveness of candesartan compared with losartan in lowering all-cause mortality rate in patients with heart failure (HF). The study used the Swedish Heart Failure Registry. The main outcome measure of the study is cited. A 90% one-year survival rate was observed in patients receiving candesartan and 83% in patients receiving losartan. Results indicated that the use of candesartan lowers the mortality risk of patients with heart failure, compared with losartan.

A letter to the editor is presented focusing on the use of renin-angiotensin system (RAS) antagonists and mortality in patients with heart failure with preserved ejection fraction (HFPEF) as reported by researcher L. H. Lund and his colleagues.

A letter to the editor is presented in response to the article "Association of treatment with losartan vs candesartan and mortality among patients with heart failure" by Hviid A. and colleagues in the 2012 issue along with a reply from the authors to the same.

A response by Lars H. Lund, Lina Benson and Maria-Eklind Cervenka to letters to the editor about their article "Association of candesartan vs losartan with all-cause mortality in patients with heart failure" that was published in volume 305, issue number 2 of the journal is presented.

Presents a letter to the editor in response to the article "What Do Good Doctors Try To Do," that was previously published in the 2003 issue of the journal "Archives of Internal Medicine."

Importance: Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries., Objective: To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development., Design, Setting, and Participants: Multinational HF registry of 23 341 participants in 40 high-income, upper-middle-income, lower-middle-income, and low-income countries, followed up for a median period of 2.0 years., Main Outcomes and Measures: HF cause, HF medication use, hospitalization, and death., Results: Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a β-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper-middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower-middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper-middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower-middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper-middle-income countries (ratio = 2.4), similar in lower-middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper-middle-income countries (9.7%), then lower-middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower-middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies., Conclusions and Relevance: This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.