From the Guidelines
Beta blockers should be continued in patients with sepsis who are already on these medications, as discontinuation has been associated with higher risk of mortality and morbidity, as seen in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The decision to continue or hold beta blockers in patients with sepsis should be based on the individual patient's hemodynamic status and underlying conditions.
- Common beta blockers include metoprolol, carvedilol, atenolol, and bisoprolol.
- Dose reduction may be necessary if the patient develops significant hypotension (typically systolic blood pressure below 90 mmHg) or bradycardia (heart rate below 50 beats per minute).
- In severe septic shock with refractory hypotension requiring multiple vasopressors, temporary discontinuation might be considered, but this should be a clinical decision based on the individual patient's hemodynamic status, as suggested by the 2013 ACCF/AHA guideline for the management of heart failure 1. The physiological rationale for continuing beta blockers includes maintaining hemodynamic stability, preventing catecholamine surge, and protecting the heart from stress-induced cardiomyopathy, which is supported by the executive summary of the guidelines on the diagnosis and treatment of acute heart failure by the European Society of Cardiology 1. Once the sepsis is resolving and the patient is hemodynamically stable, beta blockers should be restarted if they were temporarily held, typically at a lower dose initially with gradual titration back to the maintenance dose.
- The 2022 AHA/ACC/HFSA guideline for the management of heart failure recommends that oral GDMT, including beta blockers, should not be withheld for mild or transient reductions in blood pressure or mild deteriorations in renal function 1.
- The benefits of continuing beta blockers in patients with sepsis outweigh the risks, and the decision to discontinue or reduce the dose should be made on a case-by-case basis, considering the individual patient's clinical status and response to treatment.
From the Research
Beta Blockers in Sepsis
- The use of beta blockers in patients with sepsis has been a topic of debate, with some studies suggesting potential benefits and others raising concerns about their safety and efficacy 2, 3, 4, 5, 6.
- A systematic review of 14 trials found that beta blockers reduced heart rate in patients with sepsis without decreasing blood pressure, and four out of six trials that assessed mortality showed substantial benefits 2.
- An observational study of 114 patients with sepsis found that those who were taking beta blockers before admission to the ICU had lower mortality rates compared to those who were not taking beta blockers (26.31% vs 47.36%, P = 0.033) 3.
- A review of evidence on the management of sepsis in patients with preexisting heart failure suggested that beta blockers may be continued in the absence of acute hemodynamic decompensation, and that they may have independent benefits in sepsis 4.
- Another study found that long-term beta blocker therapy was associated with decreased mortality rates in patients hospitalized with sepsis who exhibited absolute and relative tachycardia (odds ratio, 0.406; 95% confidence interval, 0.177-0.932) 6.
Key Findings
- Beta blockers may reduce heart rate in patients with sepsis without decreasing blood pressure 2.
- Beta blockers may improve mortality rates in patients with sepsis, particularly those with preexisting heart failure or tachycardia 3, 4, 6.
- The use of beta blockers in sepsis is still under debate, and further research is needed to confirm their safety and efficacy 2, 5.
Considerations for Clinical Practice
- Beta blockers should be continued in patients with sepsis who were taking them before admission to the ICU, unless contraindicated 3.
- Beta blockers may be considered in patients with sepsis who exhibit tachycardia or have preexisting heart failure, after careful evaluation of their individual risk-benefit profile 4, 6.