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Use of beta blockers in heart failure with reduced ejection fraction

Author
Wilson S Colucci, MD
Section Editor
Stephen S Gottlieb, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

In patients with heart failure with reduced ejection fraction (HFrEF), randomized trials have shown that chronic blockade of beta adrenergic receptors improves symptoms, reduces hospitalization, and enhances survival even though acute effects are often detrimental [1-3]. Therefore, beta blockers are an important component of therapy in patients with current or prior symptoms of HFrEF (figure 1). (See "Pharmacologic therapy of heart failure with reduced ejection fraction".)

The use of beta blockers in the treatment of HFrEF will be discussed here. The possible roles of beta blockers in asymptomatic left ventricular dysfunction and in patients with HF with preserved EF are discussed separately. (See "Management and prognosis of asymptomatic left ventricular systolic dysfunction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)

EFFECTS OF BETA BLOCKERS IN HEART FAILURE

Mechanism of action — The mechanism of benefit from beta blocker therapy in patients with heart failure with reduced ejection fraction (HFrEF) is likely related to reducing detrimental effects of catecholamine stimulation including elevated heart rate, increased myocardial energy demands, adverse remodeling due to cardiac myocyte hypertrophy and death, interstitial fibrosis, impaired beta-adrenergic signaling, arrhythmia promotion, and stimulation of other detrimental systems such as the renin-angiotensin-aldosterone axis [4,5]. The sympathetic nervous system is activated in patients with asymptomatic left ventricular dysfunction, and further activated in patients with symptoms [6]. An elevated plasma norepinephrine concentration is a marker for poor survival in patients with HFrEF [7]. (See "Pathophysiology of heart failure: Neurohumoral adaptations" and "Predictors of survival in heart failure due to systolic dysfunction", section on 'Neurohumoral activation and heart rate'.)

Beta blocker therapy may have the following effects in patients with HF:

Reduction of detrimental direct effects of catecholamines on myocardium – Long-term exposure to catecholamines is directly detrimental to the myocardium in both animals and humans [8-10]. The effect of catecholamines on the heart and the likelihood of developing HF may be amplified by gene polymorphisms in adrenergic receptors that enhance cardiac sympathetic activity [11].

                                       

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Literature review current through: Nov 2016. | This topic last updated: Wed Jul 20 00:00:00 GMT 2016.
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