Can beta blockers (beta-adrenergic blocking agents) be continued in patients with heart failure (HF) exacerbation who are hemodynamically stable?

Continuing Beta-Blockers in Heart Failure Exacerbation

Beta-blockers should be continued during heart failure exacerbation in hemodynamically stable patients who are already on chronic beta-blocker therapy. 1, 2

When to Continue Beta-Blockers

In patients with HFrEF experiencing symptomatic exacerbation requiring hospitalization, guideline-directed medical therapy (GDMT) including beta-blockers must be continued unless hemodynamic instability or contraindications exist. 1

Criteria for Continuation:

• Hemodynamic stability is the key determinant—patients without hypotension with hypoperfusion can safely continue beta-blockers 1, 2
• Absence of requirement for intravenous inotropic support 1
• No evidence of cardiogenic shock 3

The 2013 ACC/AHA guidelines provide Class I, Level B evidence that continuing beta-blockers during hospitalization for HF exacerbation results in better outcomes compared to withdrawal. 1 This recommendation reflects consistent evidence that discontinuing beta-blockers exposes patients to unnecessary risk of clinical deterioration and increased mortality. 2, 4

When to Reduce or Withhold Beta-Blockers

Temporary Dose Reduction Should Be Considered:

• Marked volume overload requiring aggressive diuresis 1
• Marginal or low cardiac output states 1
• Recent initiation or uptitration of beta-blocker therapy prior to admission 1
• Development of symptomatic bradycardia or heart block 3
• Hypotension accompanied by clinical evidence of hypoperfusion 1

Complete Withdrawal Only When:

• Requirement for intravenous inotropic agents (dobutamine, milrinone) 1, 2
• Cardiogenic shock with hypoperfusion 2
• Severe symptomatic bradycardia unresponsive to dose reduction 3

Important caveat: Even when beta-blockers must be temporarily reduced or held, the plan should always include reintroduction and uptitration once the patient stabilizes. 1

Initiating Beta-Blockers During Hospitalization

For patients not previously on beta-blockers, initiation can occur during hospitalization but only after specific conditions are met:

• Optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropes 1
• Patient is clinically stable without signs of congestion 1
• Start at very low doses (bisoprolol 1.25 mg daily, carvedilol 3.125 mg twice daily, or metoprolol 12.5-25 mg daily) 1

Use extreme caution when initiating beta-blockers in patients who required inotropic support during their hospital course. 1

Practical Management Algorithm

For Patients Already on Beta-Blockers:

1. Assess hemodynamic status on admission 2

   • If stable (adequate perfusion, no inotrope requirement): Continue current dose 1
   • If marked volume overload but adequate perfusion: Continue beta-blocker, intensify diuretics 1
   • If low output state or requiring inotropes: Reduce dose by 50% or temporarily hold 1

2. Monitor daily during hospitalization 2:

   • Heart rate and blood pressure 1
   • Signs of congestion and perfusion 2
   • Daily weights 2
   • Serum electrolytes, BUN, creatinine 2

3. Before discharge 2:

   • Ensure beta-blocker is restarted if temporarily held 1
   • Provide clear uptitration plan 2
   • Emphasize adherence and warn against abrupt discontinuation 3

Critical Warnings

Abrupt withdrawal of beta-blockers can precipitate severe clinical deterioration, including exacerbation of angina, myocardial infarction, ventricular arrhythmias, and increased mortality—particularly in patients with underlying coronary artery disease. 3, 1 The FDA label specifically warns against routine discontinuation even during major surgery. 3

The evidence consistently demonstrates that maintaining beta-blocker therapy during acute decompensated heart failure hospitalizations reduces both in-hospital and short-term mortality compared to withdrawal. 4 Studies show approximately 85% of patients can tolerate continuation of beta-blocker therapy during hospitalization when managed appropriately. 1

Managing Common Complications

Worsening Congestion:

• First-line: Increase diuretic dose 1
• Second-line: Temporarily reduce beta-blocker dose by 50% only if diuretic intensification fails 1

Symptomatic Hypotension:

• Reduce or discontinue vasodilators first 1
• Administer beta-blocker and ACE inhibitor at different times of day 1
• Decrease diuretics if volume depleted 1
• Reduce beta-blocker dose only if hypotension persists with evidence of hypoperfusion 1

Bradycardia:

• If asymptomatic: No intervention required 1
• If symptomatic or heart rate <50 bpm: Reduce beta-blocker dose 3
• Review and reduce other rate-lowering medications 1