From the Guidelines
Beta blockers should be held in acute heart failure if the patient develops hypoperfusion or requires the use of intravenous positive inotropic drugs, as they can worsen the condition by reducing cardiac contractility and heart rate, which are compensatory mechanisms needed during acute decompensation. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, withholding or reducing beta-blocker therapy should be considered in patients with marked volume overload or marginal low cardiac output. The negative inotropic effect of beta blockers can lead to further hemodynamic compromise in patients already experiencing pump failure. Additionally, beta blockers can mask tachycardia, an important clinical sign of worsening heart failure.
- Key points to consider when managing beta blockers in acute heart failure include:
- The potential for beta blockers to worsen hypoperfusion or reduce the effectiveness of positive inotropic drugs
- The importance of cautious reintroduction of beta blockers at low doses once the patient is stabilized and euvolemic
- The need for close monitoring during the titration of beta blockers to avoid detrimental effects
- The 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults also supports the idea that beta blockers should not be discontinued in patients with heart failure unless necessary, as discontinuation can increase the risk of clinical decompensation 1.
- In general, the decision to hold beta blockers in acute heart failure should be made on a case-by-case basis, taking into account the individual patient's clinical status and the potential risks and benefits of continuing or discontinuing beta-blocker therapy.
From the FDA Drug Label
WARNINGS Heart Failure Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock. If signs or symptoms of heart failure develop, treat the patient according to recommended guidelines. It may be necessary to lower the dose of metoprolol or to discontinue it
- Beta blockers can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock.
- In acute heart failure, it may be necessary to lower the dose of metoprolol or to discontinue it, as it can worsen the condition 2.
From the Research
Reasons to Hold Beta Blockers in Acute Heart Failure
- Beta blockers can be hazardous in patients with severe acute heart failure, including those with resolved cardiogenic shock 3
- The main reasons for not using beta blockers in acute heart failure include low cardiac output syndrome, bradycardia, severe hypotension or shock, and chronic obstructive pulmonary disease 4
- Patients who are intolerant to beta blockers or do not use them have a higher frequency of adverse clinical outcomes, including longer hospital stay, greater use of vasoactive drugs, sepsis, and higher mortality rate during hospitalization 4
Clinical Considerations
- The role of beta blockers in heart failure has been long debated, and data concerning their use in patients with acute heart failure are limited 5
- Beta blockers are recommended for patients with heart failure and reduced ejection fraction for their long-term benefits, but their use in acute heart failure requires careful consideration 3, 4, 5
- The initiation or continuation of beta blockers in patients hospitalized for acute heart failure should be evaluated on a case-by-case basis, taking into account the patient's clinical characteristics and tolerance to the medication 4
Management of Beta Blockers
- There is no one-size-fits-all approach to managing beta blockers in acute heart failure, and the decision to start or stop beta blockers should be based on individual patient factors 3, 5
- A low-dose beta blocker in combination with milrinone may be considered as an adjunct therapy for acute decompensated heart failure patients with tachycardia 6