beta blockers in cardiac failure

Last edited 10/2018

• there is evidence that beta-blockers can improve prognosis in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (1,2)
  
  
• offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first (3)
  
  
• offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including (3):
  • older adults and
  • patients with:
    • peripheral vascular disease
    • erectile dysfunction
    • diabetes mellitus
    • interstitial pulmonary disease and
    • chronic obstructive pulmonary disease (COPD) without reversibility
      
      
• introduce beta-blockers in a 'start low, go slow' manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker (3)
  
  
  • beta-blocker therapy should be started at a very low dose (e.g. carvedilol 3.125mg once daily) and titrated slowly over a period of weeks or months
    • the beta-blocker should be up-titrated at fortnightly intervals (or longer in more sensitive patients) to a target dose of carvedilol 25-50mg bd or bisoprolol 10mg od (2,4)
      
      
• switch stable patients who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure due to left ventricular systolic dysfunction, to a beta-blocker licensed for heart failure
• there may be some early symptomatic deterioration during beta-blocker therapy (4)
• beta-blockers do not provide an instant beneficial effect in CHF
  • initially patients may feel more tired and they may experience symptoms of worsening fluid retention requiring a temporary increase in diuretic therapy
  • beneficial effects on LV function can take 3 to 6 months to appear

Notes:

• there is evidence that carvedilol reduced the risk of all cause mortality and combined mortality and general and specific hospital admission in severe heart failure (5) - these results were regardless of pretreatment systolic blood pressure
• use of beta-blockers in in patients >/=70 years, regardless of ejection fraction. There is evidence that, in this patient population, nebivolol, a beta-blocker with vasodilating properties, is an effective and well-tolerated treatment for heart failure in the elderly (6)
• the magnitude of the prognostic benefit conferred by beta-blockers in the absence of ACE-I appears to be similar to those of ACE-Is in systolic CHF (7)
• a meta-analysis has shown that beta-blockers appear to effectively reduce the occurrence of AF in patients with systolic HF (8)
• heart rate reduction and beta blockers in heart failure
  • a meta-analysis (9) found that the extent of heart rate reduction in patients with chronic heart failure treated with beta-blockers was significantly associated with survival benefit in trials, whereas the dose of beta-blocker was not
    • for every 5 beats/minute reduction in heart rate using beta-blocker treatment, the relative risk of death was decreased by 18%, although the heart rate reduction at which this benefit stops is not known

Reference:

• 1) British Heart Foundation. Factfile 11/99.
• 2) Geriatric Medicine (2005); 35 (1):37-42.
• 3) NICE (September 2018). Chronic heart failure
• 4) British Heart Foundation. Factfile 4/06.
• 5) Rouleau et al (2004). Influence of pretreatment systolic blood pressure on the effect of carvedilol in patients with severe chronic heart failure: the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) study. J Am Coll Cardiol;2004;43:1423-9
• 6) Flather MD et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J 2005; 26:215-25
• 7) Krum H et al. Prognostic benefit of beta-blockers in patients not receiving ACE-inhibitors. Eur Heart J 2005;26:2154-8.
• 8) Nasr IA et al. Prevention of atrial fibrillation onset by beta-blocker treatment in heart failure: a meta-analysis.Eur Heart J. 2007 Feb;28(4):457-62.
• 9) McAlister FA, Wiebe N, Ezekowitz JA, et al. Meta-analysis: beta-blocker dose, heart rate reduction and death in patients with heart failure. Ann Intern Med 2009;150:784-94