Beta blockers for HFrEF

Treatment of heart failure with reduced ejection fraction (HFrEF) with a heart failure–specific beta blocker (in combination with a renin-angiotensin system inhibitor) reduces the symptoms of heart failure, improves left ventricular ejection fraction, and reduces hospitalisation and mortality (including sudden death).

Beta blockers that improve clinical outcomes in HFrEF are bisoprolol, carvedilol, metoprolol succinate and nebivolol. Patients already taking a different beta blocker for a comorbidity (eg angina, hypertension) should be switched to one of these heart failure–specific beta blockers.

Treat all patients with HFrEF with a heart failure–specific beta blocker, including patient groups in whom beta blockers are usually avoided (eg older patients, patients with erectile dysfunction, interstitial lung disease, chronic obstructive pulmonary disease without reversibility, peripheral artery disease). Beta-blocker therapy in patients with peripheral artery disease with critical limb-threatening ischaemia needs careful consideration; see Critical limb-threatening ischaemia for more information.

Beta-blocker therapy can initially worsen heart failure and cause severe hypotension and bradyarrhythmias. These complications are due to the drug blocking sympathetic nervous system support for the failing heart. Beta-blocker therapy is an essential component of combination therapy for HFrEF, so, to minimise these complications:

• do not start beta-blocker therapy during a period of acute decompensation or if the patient has signs of congestion
• start therapy with a very low dose
• increase the dose very gradually
• monitor the patient’s symptoms frequently and measure weight daily.

Start a beta blocker (along with a renin-angiotensin system inhibitor, mineralocorticoid receptor antagonist and sodium-glucose co-transporter 2 inhibitor) at diagnosis or within 2 to 4 weeks of diagnosis of HFrEF. For patients with clinical signs of congestion, start a beta blocker when they are euvolaemic; see Starting drug therapy for HFrEF. The best approach is to ‘start low and go slow’. Double the dose every 2 to 4 weeks, provided the patient is haemodynamically stable. Aim for the highest tolerated dose within the recommended range. Use: