From the Guidelines
Beta blockers should be prescribed to all stable heart failure patients with reduced ejection fraction (HFrEF) unless contraindicated, as they provide significant benefits in reducing morbidity and mortality, with a 30% reduction in mortality and a 40% reduction in hospitalizations, as demonstrated in multiple clinical trials, including a meta-analysis published in JAMA 1. The benefits of beta blockers in patients with heart failure are well-established, with numerous studies demonstrating their effectiveness in improving outcomes, including a 2020 report from the American College of Cardiology/American Heart Association task force on performance measures, which recommends the use of beta blockers proven to reduce mortality, such as bisoprolol, carvedilol, and sustained-release metoprolol succinate, for all patients with current or prior symptoms of HFrEF, unless contraindicated 1. Some key points to consider when prescribing beta blockers for heart failure patients include:
- Initiating therapy at low doses and gradually titrating upward every 2-4 weeks as tolerated until reaching target doses or maximum tolerated doses
- Monitoring patients closely for potential side effects, such as fatigue, dizziness, and bradycardia
- Temporarily reducing beta blockers rather than abruptly discontinuing them during acute decompensation
- Using beta blockers in conjunction with other guideline-directed medical therapies, including ACE inhibitors/ARBs/ARNI, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, when appropriate. Common beta blockers used in heart failure include:
- Carvedilol (starting at 3.125 mg twice daily, target 25-50 mg twice daily)
- Metoprolol succinate (starting at 12.5-25 mg daily, target 200 mg daily)
- Bisoprolol (starting at 1.25 mg daily, target 10 mg daily). It is essential to note that beta blockers are contraindicated in patients with severe bradycardia, high-degree heart block without a pacemaker, or cardiogenic shock, and should be used with caution in patients with other comorbidities, as recommended by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.
From the FDA Drug Label
In some patients with compensated cardiac failure it may be necessary to utilize them. In such a situation, they must be used cautiously. In some cases, beta-blocker therapy can be continued while heart failure is treated with other drugs
The benefits of beta blockade in patients with heart failure include the possibility of continued therapy in patients with compensated cardiac failure, and the potential to continue beta-blocker therapy while treating heart failure with other drugs, under careful observation 2.
From the Research
Benefits of Beta Blockade in Heart Failure
The benefits of beta blockade in patients with heart failure are numerous, including:
- Reduced mortality rates, as shown in studies such as 3 and 4
- Improved quality of life, as reported in 3
- Decreased hospitalization rates, as demonstrated in 5
- Reduced morbidity, as shown in 3 and 5
- Improved symptom control, as reported in 3 and 6
Specific Benefits of Beta Blockers
Specific beta blockers, such as:
- Bisoprolol, have been shown to reduce all-cause mortality and sudden death in patients with chronic heart failure, as demonstrated in 4
- Carvedilol, has been shown to improve cardiac mortality and morbidity in patients with heart failure with reduced ejection fraction, as reported in 6
- Metoprolol succinate, has been shown to improve cardiac mortality and morbidity in patients with heart failure with reduced ejection fraction, as reported in 6
Patient Selection and Dosing
When selecting patients for beta blockade, it is essential to consider:
- The presence of contraindications, such as atrial fibrillation or diabetes, as reported in 3
- The patient's heart rate, with high-dose beta blockers recommended for patients with heart failure with preserved ejection fraction and elevated heart rate, as demonstrated in 5
- The initiation of beta blockers at small doses and titrating upward as tolerated to achieve the desired clinical effects, as reported in 3 and 6