Do we resume beta (β) blockers in acute exacerbation of heart failure (HF)?

From the Guidelines

Beta blockers should generally be continued during acute heart failure exacerbations, but may need temporary dose reduction or brief discontinuation in cases of cardiogenic shock, severe hypotension, or bradycardia. For stable patients already on beta blockers, maintain the current dose. For unstable patients, reduce the dose by 50% or temporarily hold if hemodynamically compromised. Common beta blockers used in heart failure include carvedilol (3.125-25 mg twice daily), metoprolol succinate (12.5-200 mg daily), and bisoprolol (1.25-10 mg daily) 1. Once the patient stabilizes, restart at a low dose (e.g., carvedilol 3.125 mg twice daily) and gradually uptitrate. Abrupt discontinuation can worsen heart failure due to upregulation of beta receptors and catecholamine surge.

Key Considerations

• Beta blockers are beneficial in heart failure by reducing sympathetic stimulation, decreasing heart rate and myocardial oxygen demand, preventing arrhythmias, and promoting reverse remodeling 1.
• They should be restarted before discharge if temporarily discontinued, with close follow-up to ensure proper titration.
• Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents 1.
• Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course 1.

Management Strategies

• For stable patients, maintain the current dose of beta blockers.
• For unstable patients, reduce the dose by 50% or temporarily hold if hemodynamically compromised.
• Once the patient stabilizes, restart at a low dose and gradually uptitrate.
• Temporary discontinuation is advised in shocked or severely hypoperfused patients, with re-institution of treatment attempted before discharge 1.

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

• The FDA drug label does not provide direct guidance on resuming beta blockers in acute exacerbation of heart failure (HF).
• However, it does mention that if signs or symptoms of heart failure develop, treatment should be according to recommended guidelines, and it may be necessary to lower the dose or discontinue metoprolol.
• Therefore, the decision to resume beta blockers in acute exacerbation of HF should be made on a case-by-case basis, considering the individual patient's condition and according to recommended guidelines 2.
• Caution is advised when considering resuming beta blockers in patients with acute exacerbation of HF.

From the Research

Resuming Beta Blockers in Acute Exacerbation of Heart Failure

• The decision to resume beta blockers in acute exacerbation of heart failure (HF) should be based on individual patient assessment, considering the severity of HF and the patient's response to treatment 3, 4.
• Beta blockers have been shown to reduce mortality and hospitalization in patients with Class II to IV heart failure, and their use is recommended in patients with systolic heart failure 3, 5.
• In patients with acute heart failure, beta blockers can be continued or resumed when the patient is stabilized, but the dose may need to be adjusted based on the patient's clinical condition 4, 6.
• The choice of beta blocker and the dosing strategy should be individualized, taking into account the patient's specific needs and comorbidities 3, 7.
• It is essential to monitor patients closely when resuming beta blockers in acute exacerbation of HF, as they may be at risk of adverse effects, such as bradycardia or hypotension 3, 6.

Key Considerations

• The severity of heart failure and the patient's response to treatment should guide the decision to resume beta blockers 4, 6.
• The dose of beta blockers may need to be adjusted based on the patient's clinical condition, and patients should be monitored closely for adverse effects 3, 6.
• The choice of beta blocker should be individualized, taking into account the patient's specific needs and comorbidities 3, 7.
• Beta blockers have been shown to reduce mortality and hospitalization in patients with Class II to IV heart failure, and their use is recommended in patients with systolic heart failure 3, 5.