How do beta blockers worsen chf

This study reinforces the proposal that beta-blockers should be up-titrated guided by tolerance, and that, wherever possible, physicians should aim to maintain a beta-blocker at a low dose rather than interrupting the treatment.

In addition, an event history analysis of competitive risks in CIBIS II showed that all attempts to resume bisoprolol therapy should be made if temporary withdrawal is clinically required. The maximum tolerated dose of a beta-blocker varies widely between individuals. In the Bisoprolol Experience study, which included patients treated for CHF in general practice, the maximum tolerated dose of bisoprolol ranged from 1.

This progressive and individualized method of beta-blocker administration has allowed a perceived contraindication for beta-blockade to become a well-documented indication. The aim is to individualize the treatment by slowly working towards the maximum tolerated dose, at which full receptor occupancy may be attained. Data from patients with moderate to severe CHF showed a close relationship between sympathetic activation plasma norepinephrine levels and prognosis. Reproduced with permission from Cohn et al.

Reproduced with permission from Benedict et al. Prognostic significance of plasma norepinephrine in patients with asymptomatic left ventricular dysfunction. Circulation ; 94 — Chronological progression of landmark studies on ACE-inhibitors and beta-blockers.

Adapted and reprinted with permission from European Society of Cardiology. Cause-specific adverse events leading to the withdrawal of study drug according to the absolute value for net difference between randomization groups in MERIT-HF.

Some patients may have been withdrawn due to more than one adverse event. In CHF, the dose-response curve may be shifted to the left, so that the patients are more sensitive to beta-blockers than those without CHF, and the adverse events curve is closer to the dose-response curve than it is in patients without CHF. Percentage of patients unable to tolerate carvedilol treatment, grouped according to NYHA functional class in a retrospective analysis of consecutive patients with CHF. A similar degree of heart rate reduction was achieved in both the high- and low-dose groups.

Risks of various outcomes with bisoprolol vs. Bisoprolol reduced mortality and other outcomes regardless of dose tertile. Data from Simon et al. Distribution of maximum tolerated dose of bisoprolol in CHF patients in primary care. Reproduced with permission from European Society of Cardiology.

Stock JP. Beta adrenergic blocking drugs in the clinical management of cardiac arrhythmias. Am J Cardiol ; 18 : — Alterations of cardiac sympathetic neurotransmitter activity in congestive heart failure. Am J Cardiol ; 32 : — Neurohumoral control mechanisms in congestive heart failure. Am Heart J ; : — Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure. N Engl J Med ; : — Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure.

Circulation ; 82 : — SOLVD investigators. Circulation ; 94 : — Effect of chronic beta-adrenergic receptor blockade in congestive cardiomyopathy. Br Heart J ; 37 : — Prolongation of survival in congestive cardiomyopathy by beta-receptor blockade.

Lancet ; 1 : — Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Metoprolol in dilated cardiomyopathy MDC trial study group. Lancet ; : — A randomized trial of beta-blockade in heart failure. Circulation ; 90 : — Lancet ; : 9 — Eur J Heart Fail ; 3 : — The effect of carvedilol on morbidity and mortality in patients with chronic heart failure.

Randomised, placebo-controlled trial of carvedilol in patients with congestive heart failure due to ischaemic heart disease. Effect of carvedilol on survival in severe chronic heart failure. A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure.

Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure SENIORS. Eur Heart J ; 26 : — Effects of enalapril on mortality in severe congestive heart failure. Effect of direct vasodilation with hydralazine versus angiotensin-converting enzyme inhibition with captopril on mortality in advanced heart failure: the Hy-C trial. J Am Coll Cardiol ; 19 : — A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure.

Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions.

Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. Lancet ; : Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction.

Fundam Clin Pharmacol ; 11 : — Effects of carvedilol, a vasodilator-beta-blocker, in patients with congestive heart failure due to ischemic heart disease. Circulation ; 92 : — Guidelines for the diagnosis and treatment of chronic heart failure: executive summary update : The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology.

Bucindolol displays intrinsic sympathomimetic activity in human myocardium. Circulation ; : — Beta-blocker treatment in heart failure. Fundam Clin Pharmacol ; 15 : 95 — J Card Fail ; 9 : — Systematic review of the impact of beta blockers on mortality and hospital admissions in heart failure.

A randomized trial of low-dose beta blockade therapy for idiopathic dilatedcardiomyopathy. Am J Cardiol ; 55 : — This article will review the evidence concerning the safety of beta-blocker use in patients with CHF and concomitant obstructive lung disease, with specific attention to tracking the transition from myth to evidence- based practice.

Abstract Beta-adrenergic blocking agents, or beta-blockers, are indicated in the management of angina pectoris, myocardial infarction, hypertension, congestive heart failure CHF , cardiac arrhythmias, and thyrotoxicosis, and are given to reduce perioperative complications. Publication types Review. If patients are also taking digoxin, consideration should be given to reducing the digoxin dose or discontinuing the drug, especially in patients with mild heart failure.

Increased congestion might occur because of the negative inotropic effect of beta blockers. Congestion often resolves with transient intensification of diuresis. Rarely, it might necessitate dose reduction or discontinuation of the beta blocker. The management of patients with chronic heart failure who deteriorate after a period of stability on beta blocker therapy requires thoughtful evaluation. In this situation, diuresis should be intensified, by increasing the diuretic dose, adding a thiazide-like diuretic or administering a diuretic intravenously, while the beta blocker therapy is continued.

On the other hand, if the decompensation is in the form of low cardiac output in the setting of optimal fluid management, an attempt should be made to restore stable circulation with short-term intravenous infusion of a phosphodiesterase inhibitor e. If this approach fails, the beta blocker dose should be decreased, or the drug should be discontinued. Stable patients with chronic heart failure who are taken off beta blockers are at risk for circulatory deterioration and electrophysiologic instability.

If discontinuation is necessary, the dose should be decreased slowly whenever possible. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Tarik M.

Ramahi, M. Reprints are not available from the author. The author thanks Kate Rohlfs, R. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. Carvedilol Heart Failure Study Group. N Engl J Med.

Double-blind, placebo-controlled study of the effects of carvedilol in patients with moderate to severe heart failure. Carvedilol inhibits clinical progression in patients with mild symptoms of heart failure. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure.

Randomised, placebo-controlled trial of carvedilol in patients with congestive heart failure due to ischaemic heart disease. Clinical effects of beta-adrenergic blockade in chronic heart failure: a meta-analysis of double-blind, placebo-controlled, randomized trials.

Effects of enalapril on mortality in severe congestive heart failure. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions.

The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. Am J Cardiol. The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group. Long-term beta-blockade in dilated cardiomyopathy.

Effects of short- and long-term metoprolol treatment followed by withdrawal and readministration of metoprolol. This article is one in a series developed in collaboration with the American Heart Association. Guest editor of the series is Rodman D. Starke, M. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.

This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv aafp. Want to use this article elsewhere?

Get Permissions. Read the Issue. Sign Up Now. Previous: Normocytic Anemia. Nov 15, Issue. Decrease vasodilator dose. Decrease beta blocker dose. Symptoms of fluid retention Increase diuretic dose. Symptomatic bradycardia Check digoxin Lanoxin level; adjust dose if necessary.

Read the full article. Get immediate access, anytime, anywhere. Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue.

Purchase Access: See My Options close. Best Value! To see the full article, log in or purchase access.