What are the recommendations for beta (β) blocker use in a patient with Heart Failure with preserved Ejection Fraction (HFpEF) in sinus rhythm with a history of asthma?

From the Guidelines

Beta-blockers should be used with caution in patients with Heart Failure with preserved Ejection Fraction (HFpEF) who have asthma, and cardioselective beta-blockers like bisoprolol or metoprolol succinate may be considered with careful monitoring for bronchospasm. For these patients, consider starting with low doses, such as bisoprolol 1.25 mg daily or metoprolol succinate 12.5-25 mg daily, and titrate slowly every 2-4 weeks as tolerated 1. It is essential to monitor closely for signs of bronchospasm, such as wheezing or shortness of breath, especially after initiating therapy or increasing doses. If asthma symptoms worsen, reduce the dose or discontinue the beta-blocker and consider alternative treatments, such as calcium channel blockers (verapamil or diltiazem) for rate control. The benefit of beta-blockers in HFpEF is primarily for controlling heart rate if the patient has tachycardia, as they have not shown mortality benefit in HFpEF unlike in heart failure with reduced ejection fraction 1.

Some key points to consider when using beta-blockers in patients with HFpEF and asthma include:

• Ensuring the patient's asthma is optimally controlled before starting beta-blocker therapy
• Considering pulmonology consultation for complex cases
• Monitoring for signs of bronchospasm and adjusting the treatment plan accordingly
• Using cardioselective beta-blockers, which primarily block beta-1 receptors in the heart with less effect on beta-2 receptors in the lungs, reducing the risk of bronchospasm 1.

It is crucial to weigh the potential benefits of beta-blockers in controlling heart rate against the potential risks of exacerbating asthma symptoms, and to individualize treatment decisions based on the patient's specific clinical profile and needs.

From the FDA Drug Label

PATIENTS WITH BRONCHOSPASTIC DISEASE SHOULD, IN GENERAL, NOT RECEIVE BETA-BLOCKERS Because of its relative beta1-selectivity, however, bisoprolol fumarate may be used with caution in patients with bronchospastic disease who do not respond to, or who cannot tolerate other antihypertensive treatment. Since beta1-selectivity is not absolute, the lowest possible dose of bisoprolol fumarate should be used, with therapy starting at 2. 5 mg. A beta2 agonist (bronchodilator) should be made available.

The use of beta blockers, such as bisoprolol, in patients with Heart Failure with preserved Ejection Fraction (HFpEF) in sinus rhythm and a history of asthma should be approached with caution.

• Beta blockers are generally not recommended for patients with bronchospastic disease, such as asthma.
• However, bisoprolol may be used with caution in patients with bronchospastic disease who do not respond to, or cannot tolerate other treatments, starting at a low dose of 2.5 mg.
• A beta2 agonist (bronchodilator) should be made available for these patients 2.
• The decision to use beta blockers in these patients should be made on a case-by-case basis, considering the potential benefits and risks.

From the Research

Beta Blocker Use in HFpEF Patients with Sinus Rhythm and Asthma

• The use of beta blockers in patients with Heart Failure with preserved Ejection Fraction (HFpEF) and sinus rhythm is associated with reduced mortality, as shown in a study published in 2019 3.
• However, the presence of asthma may affect the use of beta blockers, as some beta blockers may exacerbate asthma symptoms.
• A study published in 2021 discussed the use of beta blockers in patients with heart failure and comorbidities, including pulmonary disease 4.
• The study suggested that bisoprolol, metoprolol, and nebivolol may be suitable options for patients with pulmonary disease, but the use of beta blockers in patients with asthma should be approached with caution.
• Another study published in 2022 found that beta blocker use was not associated with reduced mortality or morbidity in patients with HFpEF and sinus rhythm 5.
• However, a study published in 2018 found that high-dose beta blocker use was associated with a lower risk of death in patients with HFpEF and elevated heart rate 6.

Clinical Factors Associated with Beta Blocker Prescription

• A study published in 2022 found that patients with HFpEF and sinus rhythm who were prescribed beta blockers at discharge were more likely to have a prior diagnosis of hypertension and ischemic heart disease, and were less likely to have a prior diagnosis of chronic obstructive pulmonary disease 5.
• The same study found that patients on beta blockers had a lower heart rate on admission and were more likely to be using other medications such as angiotensin-converting enzyme inhibitors and loop diuretics.

Recommendations for Beta Blocker Use

• The use of beta blockers in patients with HFpEF and sinus rhythm should be individualized, taking into account the patient's clinical characteristics and comorbidities 3, 4, 5.
• Patients with asthma should be closely monitored for exacerbation of asthma symptoms when using beta blockers 4.
• High-dose beta blocker use may be beneficial in patients with HFpEF and elevated heart rate, but further studies are needed to confirm this association 6.