Therapy of heart failure with beta-blockers

In heart failure the chronic sympathetic stimulation alters the cardiac beta-adrenergic pathway. This alteration leads to a diminished contractile response to stimulation of the cardiac beta(1) receptor. A blockade of the beta(1) receptor partly restores the physiologic response to sympathetic stimulation at rest and during exercise. Several mechanisms resulting from the competitive blockade of the beta(1) receptor may be important. The major effect of beta-blockers seems to be triggered by a reduction of the heart rate at rest resulting in an increase of the left ventricular ejection fraction on the average by 7-8 %. Patients with heart failure who are treated with a beta-blocker experience initially a slight decrease of the left Ventricular function. beta-blocker therapy should therefore be initiated only in patients with stable heart failure. The starting dose of the beta-blocker has to be very small, e.g, 5 mg Metoprolol, 1.25 mg Bisoprolol or 3.125 mg Carvedilol. In a stepwise fashion the dose has to be increased to a full beta blocking effect over a period of 4-8 weeks. Despite a careful dose titration only 90 % of the patients tolerate this regimen. Patients with high resting heart rates and/or dilated cardiomyopathy will have the greatest benefit. The two main reasons for withdrawal of the beta-blocker are deterioration of heart failure or symptomatic hypotension. Symptomatic improvement and a significant increase of exercise capacity appear gradually and can be measured only after more than 1 month duration of therapy. Three multicenter studies (MDC, CIBIS I, Carvedilol) evaluated the influence of beta-blockers on prognosis of heart failure. The MDC trial demonstrated a slower progression of heart failure with Metoprolol. The MDC and the CIBIS I trial could not show a significant improvement of prognosis. The larger trial with carvedilol was the first study to demonstrate a decreased mortality in patients who initially tolerate the beta-blocker therapy. One major concern in that study is the evaluation and classification of patients in the run-in phase who do not tolerate the beta-blocker. Definite studies (BEST, CIBIS II; COMET; RESOLVD; MERIT) are designed to answer these problems and to evaluate the effect of beta-blockers on mortality. Until the results of these studies are available the main goal of treatment with beta-blockers remains symptomatic improvement. Further, there is good evidence for an additional increase in life expectancy. In order to achieve optimal medical treatment and to avoid side-effects careful clinical evaluation and management of the patients is mandatory during therapy with beta-blockers.