From the Guidelines
Beta blockers should not be withheld in acute decompensated heart failure unless there are specific contraindications, such as marked volume overload or marginal low cardiac output, as discontinuation of beta blockers has been associated with a higher risk of mortality and morbidity 1. In patients with acute decompensated heart failure, the decision to withhold beta blockers should be made on a case-by-case basis, considering the individual patient's clinical status and the potential risks and benefits of continuing or discontinuing beta blocker therapy. Some key points to consider include:
- Discontinuation of beta blockers in hospitalized patients with heart failure with reduced ejection fraction (HFrEF) has been associated with a higher risk of in-hospital mortality, short-term mortality, and the combined endpoint of short-term rehospitalization or mortality 1.
- Withholding or reducing beta-blocker therapy should be considered in patients with marked volume overload or marginal low cardiac output 1.
- Oral guideline-directed medical therapy (GDMT), including beta blockers, should not be withheld for mild or transient reductions in blood pressure or mild deteriorations in renal function 1.
- True contraindications to beta blockers are rare, such as advanced degree atrioventricular block in the absence of pacemakers, cardiogenic shock that may preclude use of certain medications until resolution of shock state, or angioedema for ACEi or ARNi 1. It's worth noting that the 2022 AHA/ACC/HFSA guideline for the management of heart failure recommends that beta blockers be continued in patients with HFrEF unless contraindicated, as they have been shown to reduce morbidity and mortality 1. In contrast, the 2013 ACCF/AHA guideline for the management of heart failure also recommends the use of beta blockers in patients with HFrEF, unless contraindicated, to reduce morbidity and mortality 1. However, the most recent and highest quality study, the 2022 AHA/ACC/HFSA guideline, should be prioritized when making clinical decisions 1.
From the FDA Drug Label
Most patients (89%) were taking beta-blockers, with 26% on guideline-defined target daily doses The main reasons for not receiving the target beta-blocker doses at baseline were hypotension (45% of patients not at target), fatigue (32%), dyspnea (14%), dizziness (12%), history of cardiac decompensation (9%), and bradycardia (6%). For the 11% of patients not receiving any beta-blocker at baseline, the main reasons were chronic obstructive pulmonary disease, hypotension, and asthma
The reason to withhold beta blockers (beta-adrenergic blocking agents) in acute decompensated heart failure is due to potential adverse effects such as:
- Hypotension
- Bradycardia
- Worsening heart failure in some cases, as beta blockers can decrease cardiac contractility and worsen symptoms in the acute decompensated phase. 2
From the Research
Reasons to Withhold Beta Blockers in Acute Decompensated Heart Failure
- Low cardiac output syndrome 3
- Bradycardia 3
- Severe hypotension or shock 3
- Chronic obstructive pulmonary disease (COPD) 3
- Decompensated heart failure, where the dose may have to be reduced or withheld temporarily 4
Clinical Outcomes of Withholding Beta Blockers
- Longer hospital stay 3
- Greater use of vasoactive drugs 3
- Higher frequency of sepsis and septic shock 3
- Higher mortality rate during hospitalization 3
General Guidance on Beta Blocker Use in Heart Failure
- Beta-blockers should be administered to all stable HF patients without contraindication and initiated as soon as possible 5
- Beta-blockers can be used in patients with acute heart failure, with a tolerance rate of 73.2% 3
- Initiating dose should be very low and increased gradually over weeks 4
- Treatment benefit appears proportional to magnitude of heart rate reduction and thus target dose should be the maximum tolerated for adequate bradycardia 4