Is it safe to initiate beta blockers in a patient with congestive heart failure (CHF) and hypotension?

From the Guidelines

Initiating beta blockers in patients with congestive heart failure (CHF) and hypotension can be done safely with proper management, as the benefits of beta blockers in reducing morbidity and mortality outweigh the risks, as shown in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. When considering the initiation of beta blockers in patients with CHF and low blood pressure, it is crucial to start with very low doses of evidence-based beta blockers such as carvedilol (3.125 mg twice daily), metoprolol succinate (12.5-25 mg daily), or bisoprolol (1.25 mg daily) 1. Some key points to consider when initiating beta blockers in these patients include:

• Ensuring the patient is euvolemic and stable, with systolic blood pressure preferably above 90 mmHg, before starting beta blockers, as recommended in the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.
• Beginning beta blocker therapy only after the patient has been stabilized on ACE inhibitors/ARBs and diuretics, as suggested by the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1.
• Monitoring blood pressure, heart rate, and symptoms closely after starting therapy, with follow-up within 1-2 weeks, to promptly address any adverse effects.
• Gradually increasing the dose of beta blockers, typically doubling the dose every 2-4 weeks as tolerated, until reaching target doses, as recommended by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.
• Temporarily reducing or holding the beta blocker rather than discontinuing completely if hypotension worsens (systolic BP <85 mmHg) or symptoms deteriorate, as the benefits of beta blockers in CHF are well-established and should not be discontinued without careful consideration 1. The benefits of beta blockers in CHF, including blocking harmful sympathetic activation, reducing heart rate, improving ventricular remodeling, and decreasing mortality, develop gradually over weeks to months, while side effects can appear immediately, necessitating a cautious approach 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.

• Initiating beta blockers in patients with CHF and hypotension is not recommended due to the risk of precipitating heart failure and cardiogenic shock.
• The patient's low BP may be a concern when starting beta blockers, as it may further decrease blood pressure.
• It is essential to weigh the benefits and risks of initiating beta blockers in this patient population, considering the potential for adverse effects on myocardial contractility and blood pressure 2.

From the Research

Initiating Beta Blockers in CHF Patients with Low BP

• The use of beta blockers in patients with congestive heart failure (CHF) has been shown to improve symptoms, reduce hospital readmission, and decrease mortality 3, 4, 5.
• Current guidelines recommend the use of beta blockers in mild, moderate, and severe CHF, in the absence of contraindications or tolerance, in combination with ACE inhibitors and diuretics 3.
• However, beta blockers should be initiated in patients after maximal medical therapy with diuretics, ACE inhibitors, and digitalis, and patients should already be stabilized and in compensated conditions 3.
• The initial dose of beta blockers should be low, with slow titration over weeks or months to attain maintenance doses 3, 6.
• Studies have shown that early initiation of beta blockers in stable HF patients can reduce the risk of mortality and morbidity, including hospitalization for worsening HF 7.
• It is essential to carefully select patients and monitor them closely for signs of clinical instability when initiating beta blocker therapy, especially in those with low BP 4, 5.

Considerations for Patients with Low BP

• Patients with CHF and low BP may require careful consideration before initiating beta blocker therapy, as they may be more susceptible to worsening hypotension 3, 5.
• However, the benefits of beta blocker therapy may outweigh the risks in these patients, and careful titration of the dose can help minimize adverse effects 3, 6.
• The choice of beta blocker and the timing of initiation should be individualized based on the patient's specific clinical characteristics and medical history 5, 7.