From the Guidelines
Beta blockers are generally contraindicated in acute pulmonary embolism (PE) with right heart strain, as they can worsen hemodynamic compromise by reducing cardiac contractility and heart rate, which are crucial compensatory mechanisms in this setting. According to the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1, the focus is on anticoagulation, systemic thrombolytic therapy, and supportive care to manage high-risk PE, without specific recommendations for beta blockers. The guidelines do suggest considering norepinephrine and/or dobutamine for patients with high-risk PE 1, which implies that maintaining cardiac output and blood pressure is a priority, and beta blockers could potentially counteract these efforts.
In the context of acute PE with right heart strain, the right ventricle faces increased afterload due to pulmonary vascular obstruction, and the heart compensates by increasing contractility and heart rate to maintain adequate systemic perfusion. Beta blockers interfere with these compensatory mechanisms by blocking beta-adrenergic receptors, potentially leading to further deterioration in cardiac output, hypotension, and even cardiogenic shock. If a patient with acute PE and right heart strain is already on chronic beta blocker therapy, careful clinical judgment is needed regarding whether to continue or temporarily discontinue the medication, weighing the risks of abrupt discontinuation against the potential hemodynamic benefits.
Key considerations in managing acute PE with right heart strain include:
- Anticoagulation with UFH, including a weight-adjusted bolus injection, as recommended by the 2019 ESC guidelines 1
- Systemic thrombolytic therapy for high-risk PE, as recommended by the 2019 ESC guidelines 1
- Supportive care to maintain cardiac output and blood pressure, which may involve the use of vasopressors like norepinephrine and/or dobutamine, as suggested by the 2019 ESC guidelines 1
- Avoidance of beta blockers, which can worsen hemodynamic compromise in this setting. Once the patient is stabilized and the acute phase has resolved, beta blockers may be reconsidered if indicated for other conditions such as coronary artery disease or arrhythmias.
From the Research
Acute PE and Right Heart Strain
- The use of beta blockers in patients with acute pulmonary embolism (PE) and right heart strain is not directly addressed in the provided studies 2, 3, 4, 5, 6.
- However, the management of acute PE focuses on hemodynamic support, anticoagulation, and thrombolysis in severe cases 2, 4, 6.
- The provided studies discuss the use of anticoagulants, such as unfractionated heparin, low-molecular-weight heparin, and direct oral anticoagulants, in the treatment of PE 3, 4, 6.
- Echocardiographic findings, such as increased right ventricle: left ventricle size ratio and tricuspid regurgitation, can suggest right ventricular strain and PE 5.
- The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 4.
Treatment of Acute PE
- Anticoagulation is the mainstay of treatment for PE, with options including unfractionated heparin, low-molecular-weight heparin, and direct oral anticoagulants 3, 4, 6.
- Thrombolysis may be considered in severe cases of PE, such as massive pulmonary embolism 6.
- The use of beta blockers is not mentioned as a treatment option for acute PE in the provided studies.
Right Heart Strain
- Right heart strain can occur in patients with PE, leading to reduced cardiac output and impaired contractility 2.
- Echocardiographic findings can help diagnose right heart strain and PE 5.
- The management of right heart strain in the context of PE focuses on hemodynamic support and anticoagulation 2, 4.