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Review
. 2023 Nov 16:10:1263482.
doi: 10.3389/fcvm.2023.1263482. eCollection 2023.

Beta-blocker management in patients admitted for acute heart failure and reduced ejection fraction: a review and expert consensus opinion

Guillaume Schurtz  1 , Nathan Mewton  2 , Gilles Lemesle  1   3   4   5 , Clément Delmas  6 , Bruno Levy  7 , Etienne Puymirat  8 , Nadia Aissaoui  9 , Fabrice Bauer  10 , Edouard Gerbaud  11   12 , Patrick Henry  13 , Laurent Bonello  14 , Thomas Bochaton  15 , Eric Bonnefoy  15 , François Roubille  16 , Nicolas Lamblin  17   18
Affiliations
Review

Beta-blocker management in patients admitted for acute heart failure and reduced ejection fraction: a review and expert consensus opinion

Guillaume Schurtz et al. Front Cardiovasc Med. .

Abstract

The role of the beta-adrenergic signaling pathway in heart failure (HF) is pivotal. Early blockade of this pathway with beta-blocker (BB) therapy is recommended as the first-line medication for patients with HF and reduced ejection fraction (HFrEF). Conversely, in patients with severe acute HF (AHF), including those with resolved cardiogenic shock (CS), BB initiation can be hazardous. There are very few data on the management of BB in these situations. The present expert consensus aims to review all published data on the use of BB in patients with severe decompensated AHF, with or without hemodynamic compromise, and proposes an expert-recommended practical algorithm for the prescription and monitoring of BB therapy in critical settings.

Keywords: acute heart failure; beta-blocker therapy; cardiogenic shock; inotropes; left ventricular systolic dysfunction.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Figures

Figure 1
Figure 1
The physiologic and pathophysiologic role of the beta-adrenergic pathway. The role of beta-adrenergic stimulation in cardiac physiology is pivotal (white circles). Intense and sustained stimulation (dotted arrow) are presumed to be responsible for the deleterious effects observed in patients with severe heart failure (gray circles).
Figure 2
Figure 2
Pharmacological properties of the different beta-blocker generations. Second and third generations show a greater β1 selectivity and, for third generation compounds, an additional vasodilatory activity. Acute hemodynamic effects reveal a safer profile with carvedilol (as compared to others) regarding cardiac index and systemic vascular resistances. PCWP, pulmonary capillary wedge pressure; SVR, systemic vascular resistance.
Figure 3
Figure 3
BB management in acute decompensated HF. This schematic overview of BB in AHF highlights the crucial role of accurate patient's hemodynamic condition assessment and its management for clinician decision making. “Facilitated” initiation strategies may be considered for the most severe patients. ACS, acute coronary syndrome; BB, beta-blocker; HF, heart failure; HT, heart transplantation; LVAD, left ventricular assist device; MCS, mechanical circulatory support; PDEI, phosphodiesterase inhibitor; RHC, right heart catheterization; RV, right ventricle; SCAI, Society of cardiovascular angiography and intervention; SGLT2I, sodium-glucose cotransporter 2 inhibitors; TTE, transthoracic echocardiography.
Figure 4
Figure 4
Practical considerations for BB introduction in patients with AHF. To minimize treatment failure and improve tolerance, introduction should only be considered after a multi-parameter evaluation, especially for congestion and perfusion status. ACEI, angiotensine converting enzyme inhibitor; BP, blood pressure; CO, cardiac output; CRT, capillary refill time; CVP, central venous pressure; HR, heart rate; IVC, inferior vena cava; MAP, mean arterial pressure; RHC, right heart catheterization; RV, right ventricle; RVFAC, right ventricular fractional area change; TAPSE, tricuspid annular plane systolic excursion; TTE, transthoracic echocardiography.
See this image and copyright information in PMC

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