When is it appropriate to initiate a beta blocker (β-blocker) in a patient with a new diagnosis of Heart Failure with Reduced Ejection Fraction (HFrEF) and acute exacerbation?

From the Guidelines

Beta blockers should be initiated in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF) only after they are hemodynamically stable and euvolemic, typically after the acute exacerbation has resolved, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

Key Considerations

• The patient should be clinically stabilized and not require intravenous inotropic support before initiating beta-blocker therapy, as stated in the 2022 guideline 1.
• The introduction of beta blockers during acute decompensation can worsen heart failure symptoms by reducing contractility and cardiac output.
• Beta blockers improve outcomes in HFrEF by reducing sympathetic activation, decreasing heart rate, improving ventricular filling, and promoting reverse remodeling.

Recommended Beta Blockers and Dosing

• Start with a low dose of an evidence-based beta blocker such as:
  • Carvedilol (3.125 mg twice daily)
  • Metoprolol succinate (12.5-25 mg daily)
  • Bisoprolol (1.25 mg daily)
• Gradually uptitrate every 2 weeks as tolerated toward target doses:
  • Carvedilol (25-50 mg twice daily)
  • Metoprolol succinate (200 mg daily)
  • Bisoprolol (10 mg daily)

Important Precautions

• Ensure the patient is not in decompensated heart failure with fluid overload, hypotension (systolic BP <90 mmHg), or bradycardia (heart rate <60 bpm) before initiating beta-blocker therapy, as recommended by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.
• Beta blockers should be part of guideline-directed medical therapy along with ACE inhibitors/ARBs/ARNI, mineralocorticoid receptor antagonists, and SGLT2 inhibitors.

From the Research

Initiation of Beta Blockers in HFrEF

• Beta blockers are a cornerstone of treatment for heart failure with reduced ejection fraction (HFrEF) and should be initiated as soon as possible after diagnosis, as they have been shown to reduce mortality and hospitalization 2, 3, 4.
• In the setting of acute exacerbation, beta blockers can be initiated once the patient is stabilized and there are no contraindications to their use 3.
• The choice of beta blocker is important, with bisoprolol, metoprolol succinate, and carvedilol being the preferred agents due to their proven efficacy in reducing mortality and hospitalization 2, 4, 5.
• The dose of beta blocker should be started at a low level and gradually increased to the maximum tolerated dose, with the goal of achieving adequate bradycardia 3, 6.

Contraindications and Precautions

• Beta blockers are not contraindicated in patients with decompensated heart failure or those with coexisting bronchospasm, but the dose may need to be reduced or withheld temporarily 3.
• Patients with intrinsic sympathomimetic activity (ISA) may have diminished efficacy with certain beta blockers, such as xamoterol, bucindolol, and nebivolol 4.
• Adverse reactions to beta blockers are associated with beta-2 blockade and alpha-blockade, and can include metabolic disturbance, bronchospasm, and sexual dysfunction 4.

Clinical Evidence

• Studies have shown that beta blockers reduce mortality and hospitalization in patients with HFrEF, with carvedilol being associated with improved survival compared to metoprolol succinate 5.
• The use of beta blockers in clinical practice is often suboptimal, with only 30-35% of patients achieving the therapeutic target dose 6.
• Referral to a heart failure clinic can improve the use of guideline-directed medical therapy, including beta blockers, in patients with newly diagnosed HFrEF 2.