Results of heart failure trials may not be generalizable to community practice. This is partly because patients in clinical trials are different. They are usually younger and more often male. They have less comorbidity and are more likely to adhere to medication regimens, compared with patients in the community.

Another factor is the treating physician. In clinical trials, doctors are more specialized. They are more likely to have support from nurses and coordinators compared with community practitioners.

A registry that illustrates experience with carvedilol in community treated heart failure patients is now available. This registry is called the Coreg Heart Failure Registry (COHERE). It includes data from 633 participating physicians on 4,273 unselected heart failure patients.

Physicians who contributed data to the COHERE registry include cardiologists and non-cardiologists who work in the community practice setting. The data set does not include the experience of full time faculty members or specialists in heart failure.

To illustrate differences between clinical trials and community practice, investigators compared COHERE registry with data from 1,094 patients in carvedilol randomized clinical trials and 2,981 patients in open label carvedilol compassionate use trials.

Investigators have not yet fully evaluated outcomes data. However, some interesting differences emerged.

The COHERE registry contained more older patients and more women than in the clinical trials. In addition, patients in COHERE had higher left ventricular ejection fraction and less severe New York Heart Association functional class than the clinical trial patients.

The COHERE patients were also less likely to be on background treatment with digoxin, diuretics and angiotensin converting enzyme inhibitors.

Titration took longer in the COHERE registry patients, and fewer patients reached target maintenance doses of 25-50 mg twice daily compared with clinical trial patients. On the other hand, most patients continued carvedilol treatment in COHERE.

Titration Experience

	Carvedilol titration experience			COHERE titration experience
	COHERE (n=3,861)	Clinical trials	Compassionate use	Cardiologists' patients (n = 2,869)	Non-cardiologists' patients (n = 992)
No. titration days	75 ± 46	NA	54 ± 32*	75 ± 45	75 ± 48
Titrated to 25-50 mg bid	45%	85%*	93%*	50%	30%**
Carvedilol discontinued	9%	12%	7%*	10%	6%**

* P < 0.001 vs. COHERE
** P < 0.001
NA = Not available

As expected, physicians participating in COHERE were less likely to be cardiologists. They were also less to have an academic affiliation or practice at a hospital.

This registry data provides a broader picture of physician practice in the community. Future observational studies should also consider the differences between clinical trials and community experience in the treatment of heart failure with beta-blockers.