From the Guidelines
Beta blockers are a crucial component of Guideline-Directed Medical Therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) and should be initiated in all stable patients unless contraindicated, as they have been shown to reduce mortality, hospitalizations, and sudden cardiac death 1. The use of beta blockers in GDMT is supported by strong evidence, including the 2022 AHA/ACC/HFSA guideline for the management of heart failure, which recommends that beta blockers be prescribed to all patients with HFrEF, unless contraindicated or not tolerated 1. Some key points to consider when using beta blockers in GDMT include:
- Initiating beta blockers at low doses and gradually uptitrating every 2 weeks as tolerated to target doses, with careful monitoring of heart rate, blood pressure, and symptoms 1
- Using one of the three beta blockers proven to reduce mortality, such as bisoprolol, carvedilol, and sustained-release metoprolol succinate, as recommended by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1
- Maintaining long-term treatment with beta blockers to reduce the risk of major cardiovascular events, even if symptoms do not improve 1
- Temporarily reducing or holding beta blockers during acute decompensated heart failure and restarting before discharge once the patient is euvolemic, and avoiding abrupt discontinuation to prevent worsening heart failure or arrhythmias. Overall, the evidence supports the use of beta blockers as a cornerstone of GDMT for HFrEF, with a focus on initiating and uptitrating these medications to target doses, monitoring for side effects, and maintaining long-term treatment to reduce morbidity and mortality 1.
From the Research
Role of Beta Blockers in Guideline-Directed Medical Therapy (GDMT)
- Beta blockers, also known as beta-adrenergic blocking agents, play a crucial role in the treatment of heart failure with reduced ejection fraction (HFrEF) as part of Guideline-Directed Medical Therapy (GDMT) 2, 3, 4, 5, 6.
- The guidelines recommend the use of one of three beta blockers (bisoprolol, carvedilol, metoprolol succinate) for the treatment of systolic heart failure (HF) 2.
- Beta blockers have been established to be effective in reducing mortality in patients with HF, with over 20 randomized, placebo-controlled clinical trials involving more than 20,000 patients demonstrating their benefit 2.
- The use of beta blockers in GDMT is based on the results of multiple major randomized controlled trials demonstrating improved clinical outcomes in patients with HFrEF who are maintained on this therapy 6.
- Beta blockers are often underutilized in the treatment of HF, possibly due to uncertainty about their safety and benefit in special populations, such as women, the elderly, African Americans, patients with diabetes, and patients with atrial fibrillation 2.
Benefits of Beta Blockers in HFrEF
- Beta blockers have been shown to reduce mortality and hospitalization in patients with Class II to IV heart failure 4.
- The treatment benefit of beta blockers appears to be proportional to the magnitude of heart rate reduction, with target doses aiming for adequate bradycardia 4.
- Beta blockers are not contraindicated in patients with decompensated heart failure or those with coexisting bronchospasm, although the dose may need to be reduced or withheld temporarily 4.
- Carvedilol may confer greater benefit in HF patients with diabetes and atrial fibrillation, as well as in African American patients 2.
Comparison of Beta Blockers
- Studies have compared the efficacy of different beta blockers, including bisoprolol, carvedilol, and metoprolol succinate, with results suggesting similar effects on mortality amongst patients with CHF 5.
- Bisoprolol and carvedilol have been associated with lower mortality compared to metoprolol succinate in some studies, although the difference was not significant in matched samples 5.