Do beta blockers (Beta-Adrenergic Blocking Agents) have a mortality benefit in Congestive Heart Failure (CHF)?

From the Guidelines

Beta blockers do provide significant mortality benefit in chronic heart failure (CHF), as demonstrated by multiple large clinical trials, including the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.

Key Points

• Multiple large clinical trials have demonstrated that beta blockers such as carvedilol, metoprolol succinate, and bisoprolol reduce mortality by approximately 30-35% in patients with heart failure with reduced ejection fraction (HFrEF) 1.
• These medications should be initiated at low doses and gradually titrated upward to target doses: carvedilol 25mg twice daily (or 50mg twice daily if >85kg), metoprolol succinate 200mg daily, or bisoprolol 10mg daily.
• Beta blockers work by blocking the harmful effects of chronic sympathetic nervous system activation in heart failure, reducing heart rate, decreasing myocardial oxygen demand, and preventing ventricular remodeling.
• They should be started in stable patients, not during acute decompensation, as recommended by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.
• Common side effects include fatigue, dizziness, and bradycardia, and it's essential to monitor heart rate, blood pressure, and symptoms during initiation and dose titration.
• Beta blockers are a cornerstone therapy for CHF management alongside ACE inhibitors/ARBs, mineralocorticoid receptor antagonists, and newer agents like SGLT2 inhibitors in appropriate patients, as supported by the 2013 ACCF/AHA guideline for the management of heart failure 1.

Evidence

The evidence from multiple studies, including the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1, the 2013 ACCF/AHA guideline for the management of heart failure 1, and the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 1, consistently supports the use of beta blockers in patients with HFrEF to reduce morbidity and mortality.

Clinical Implications

The use of beta blockers, such as bisoprolol, carvedilol, and sustained-release metoprolol succinate, is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality 1. It is crucial to initiate beta-blocker therapy after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents, and to start with a low dose in stable patients, as recommended by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.

From the Research

Mortality Benefit of Beta Blockers in Congestive Heart Failure

• The use of beta blockers in patients with congestive heart failure (CHF) has been shown to have a mortality benefit in several studies 2, 3, 4, 5, 6.
• A meta-analysis of 17 randomized clinical trials found that beta-blockade significantly reduced all-cause mortality in patients with CHF, with a random effect odds ratio of 0.69 (95% CI 0.54 to 0.88) 2.
• Another study found that bisoprolol, carvedilol, and metoprolol succinate had similar effects on mortality in patients with CHF, with no significant difference between the three beta-blockers 3.
• The beneficial effects of beta-blockers on mortality in patients with mild to moderate CHF have been demonstrated in several studies, including the CIBIS II, RESOLVD, and MERIT-HF studies 4.
• A meta-analysis of randomized controlled trials found that beta-blockers reduced mortality by 22% (95% CI 16 to 28) and hospitalizations for worsening heart failure by 24% (95% CI 20 to 29) 6.

Comparison of Different Beta Blockers

• The study by 3 found that bisoprolol, carvedilol, and metoprolol succinate had similar effects on mortality in patients with CHF.
• The study by 6 found that the amplitude of benefit of beta-blockers on mortality and morbidity was similar for carvedilol, metoprolol, and bisoprolol, regardless of the severity of CHF.
• The study by 2 found that carvedilol had a greater survival benefit than noncarvedilol drugs, but the difference did not reach statistical significance.

Severity of Heart Failure and Beta Blocker Benefit

• The study by 6 found that the benefit of beta-blockers on mortality and morbidity was similar regardless of the severity of CHF, assessed by left ventricular ejection fraction or New York Heart Association classification.
• The study by 4 found that beta-blockers improved survival in patients with mild to moderate CHF, and that the beneficial effects of beta-blockers on mortality were similar in patients with severe CHF.