From the Guidelines
Beta blockers are a crucial component in the management of heart failure, as they have been shown to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF), and their use is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, as stated in the 2013 ACCF/AHA guideline for the management of heart failure 1. The benefits of beta blockers in heart failure management can be attributed to their ability to slow heart rate, reduce blood pressure, and decrease the heart's workload, allowing it to pump more efficiently over time.
- Typical starting doses are low (e.g., carvedilol 3.125mg twice daily, metoprolol succinate 12.5-25mg daily, or bisoprolol 1.25mg daily) and are gradually increased every 2-4 weeks as tolerated to target doses (carvedilol 25-50mg twice daily, metoprolol succinate 200mg daily, or bisoprolol 10mg daily).
- Beta blockers work by blocking beta-adrenergic receptors, preventing norepinephrine and epinephrine from overstimulating the heart, which reduces the heart's oxygen demand, prevents harmful cardiac remodeling, and improves left ventricular function.
- Long-term treatment with beta blockers can lessen the symptoms of HF, improve the patient’s clinical status, and enhance the patient’s overall sense of well-being, as well as reduce the risk of death and the combined risk of death or hospitalization, as seen in patients with or without coronary artery disease (CAD) and in patients with or without diabetes mellitus, as well as in women and blacks 1. Patients may experience initial worsening of symptoms when starting therapy, but long-term benefits include reduced hospitalizations and improved survival, with a consistent 30% reduction in mortality and a 40% reduction in hospitalizations in patients with class II and III heart failure, as demonstrated in multiple randomized controlled clinical trials 1.
- Side effects can include fatigue, dizziness, and worsening of asthma or diabetes, so close monitoring is essential during dose adjustments. It is essential to note that the evidence supporting the use of beta-blockers in heart failure is robust, with multiple studies demonstrating their benefits in reducing morbidity and mortality, and their use is recommended in various guidelines, including the 2013 ACCF/AHA guideline for the management of heart failure 1 and the 2012 ESC guidelines for the diagnosis and treatment of acute and chronic 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
Beta blockers, such as bisoprolol, can be used in the management of heart failure in patients with compensated cardiac failure. They should be used cautiously and in some cases, can be continued while heart failure is treated with other drugs 2.
From the Research
Mechanism of Beta Blockade in Heart Failure
- Beta blockers have been shown to prolong survival in chronic heart failure by reducing mortality and morbidity in patients with impaired systolic function 3
- The reduction in heart rate is one of the mechanisms by which beta blockers exert beneficial effects in chronic heart failure 3
- Beta blockers can be initiated early, even in stable and symptom-free subjects with heart failure, and should be commenced at small doses and then titrated upward as tolerated to achieve the desired clinical effects on heart rate and symptom control 4
Comparison of Different Beta Blockers
- Comparative studies have been performed with metoprolol, a beta1-selective second-generation beta blocker, and carvedilol, a nonselective and vasodilatative third-generation beta blocker, with results indicating that carvedilol may be superior to metoprolol in improving left ventricular ejection fraction 5
- However, there is no conclusive evidence that carvedilol is superior to metoprolol in terms of prognosis, and it is not justified to substitute metoprolol with carvedilol 5
- A study comparing the efficacy of bisoprolol, carvedilol, and metoprolol in reducing mortality and hospitalizations among heart-failure patients found no significant differences between the three beta-blocker groups in terms of mortality, hospitalizations, or ICU admissions 6
Clinical Outcomes and Patient Satisfaction
- The use of beta blockers, such as bisoprolol, carvedilol, and metoprolol succinate, can improve patient satisfaction and quality of life in subjects with heart failure 4
- A study evaluating the comparative efficacy of different beta blockers found that patients on bisoprolol and carvedilol exhibited a slight improvement in New York Heart Association (NYHA) class and LVEF, though this was not statistically significant 6
- Side effects, including bradycardia, fatigue, and hypotension, were noted in patients treated with beta blockers, highlighting the need for careful dose titration and monitoring 6
Treatment Recommendations
- The current recommendations of the American College of Cardiology/ American Heart Association suggest a mortality benefit with the use of β-blockers in chronic HF, especially for bisoprolol, carvedilol, and sustained-release metoprolol succinate 4
- The use of these three agents should be recommended for all stable subjects with current or previous symptoms of heart failure and heart failure with reduced ejection fraction unless there is any contraindication 4
- Cardiologists should weigh the benefit-risk in subjects with heart failure and other coexisting cardiovascular problems such as atrial fibrillation and diabetes 4