From the Guidelines
Beta blockers should not be held in patients with heart failure with reduced ejection fraction (HFrEF) unless contraindicated or not tolerated, as they reduce the risk of death and hospitalization, and improve symptoms and clinical status. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, treatment with beta blockers has been shown to improve left ventricular ejection fraction (LVEF), lessen symptoms of heart failure, and improve clinical status. The benefits of beta blockers were observed in various patient populations, including those with or without coronary artery disease, diabetes, and across different age, sex, and racial groups.
Key points to consider when using beta blockers in heart failure management include:
- Initiating beta blockers at low doses and titrating up to target doses as tolerated 1
- Maintaining long-term treatment to reduce the risk of major cardiovascular events, even if symptoms do not improve
- Temporarily holding or reducing beta blockers during acute decompensated heart failure until the patient is stabilized
- Cautiously reintroducing beta blockers at a lower dose and gradually titrating back up to the target dose once the patient is stabilized
Common beta blockers used in heart failure include carvedilol, metoprolol succinate, and bisoprolol, with specific dosing and titration recommendations outlined in the guidelines 1. Overall, the use of beta blockers is a cornerstone of heart failure management, and their benefits in reducing morbidity, mortality, and improving quality of life make them a crucial component of treatment for patients with HFrEF.
From the FDA Drug Label
Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock. If signs or symptoms of heart failure develop, treat the patient according to recommended guidelines. It may be necessary to lower the dose of metoprolol or to discontinue it
Beta blockers are not held in Congestive Heart Failure (CHF), but rather, they can precipitate or worsen heart failure in some cases. However, the dose may need to be lowered or discontinued if signs or symptoms of heart failure develop. 2
From the Research
Beta Blockers in CHF
- Beta-blockers are not contraindicated in congestive heart failure (CHF) and are actually a cornerstone treatment for the condition 3, 4, 5, 6, 7
- Studies have shown that beta-blockers such as bisoprolol, carvedilol, and metoprolol succinate can reduce mortality and hospitalization in patients with Class II to IV heart failure 3, 5
- The benefits of beta-blockers in CHF are thought to be proportional to the magnitude of heart rate reduction, and target doses should be the maximum tolerated for adequate bradycardia 3
- Beta-blockers can be used in patients with decompensated heart failure or those with coexisting bronchospasm, although the dose may need to be reduced or withheld temporarily 3
- The choice of beta-blocker is important, as not all beta-blockers are equally effective in treating CHF, with bisoprolol, metoprolol succinate, and carvedilol being the most effective options 5
Initiation and Titration of Beta Blockers
- Beta-blockers should be initiated at a low dose and gradually increased over weeks to minimize adverse effects 3, 4
- The initial effects of beta-blockers may be neutral or adverse, but benefits accumulate gradually over a period of weeks to months 4
- Patients and physicians need to be patient and persistent when initiating beta-blocker therapy, as the full benefits may take time to develop 4
Specific Patient Populations
- Beta-blockers are effective in reducing mortality and hospitalization in patients with systolic heart failure, but their effectiveness in patients with preserved left ventricular ejection fraction (LVEF) is less clear 6
- Beta-blockers may be beneficial in patients with unstable severe acute heart failure or right ventricular failure, but more research is needed to confirm this 6