Beta-blockers in heart failure

 Haris Hasan

Departemen Kardiologi/Divisi Kardiologi Dep. Ilmu. Peny. Dalam

FKUSU/RSHAM

Medan

Less tan !" years ago #e #ere taugt tat $eta%$lo&'ers #ere a&tually

&ontraindi&ated in eart (ailure. Ho#ever) te eviden&e as $een mounting and trials

su& as *I+IS,) M-RI%HF  and S-0I1RS!  ave so#n tat $eta%$lo&'ers) #en used

alongside A*- ini$itors) redu&e mortality $y up to a tird. is is an astonising

(igure and yet many people #it eart (ailure are still not treated #it $eta $lo&'ers. e

su&&ess(ul use o( $eta%$lo&'ers in large) randomised) &ontrolled trials as led te -S*

to re&ommend teir use in all suita$le patients (ollo#ing A*- ini$ition even i( tey

are asymptomati&) unless tere is a &ontraindi&ation to teir use. e *I+IS III trial 2

suggests tat $eta%$lo&'ers may $e initiated $e(ore A*- ini$ition.

Mechanism of action

e simple ans#er to tis is tat #e are not entirely sure3 +eta%$lo&'ers redu&e te e((e&ts o(

te sympateti& nervous system4s 5(igt or (ligt4 response) #i& in eart (ailure as $een

set o(( in response to an in&rease in RAAS a&tivity 6Fig. ,7. ey $lo&' stimulation o( te

 $eta%re&eptors in te eart and ave a negative inotropi& a&tion) #i& lessens &ardia&

#or'load) as te (or&e and rate o( te eart$eat is redu&ed and undesira$le remodelling o( te

eart is minimised.

 

How to use and time use

e -S* guidelines suggest te (ollo#ing approa&8 As a $eta%$lo&'er a&tion may $e

 $ipasi& #it long%term improvement) possi$ly pre&eded $y initial #orsening) $eta%$lo&'ers

sould $e initiated under &are(ul &ontrol. e initial dose sould $e small and in&reased

slo#ly and progressively to te target dose used in te large &lini&al trials. Up%titration sould

 $e adapted to individual responses. It is evident tere(ore tat even a lo# dose o( a $eta%

 $lo&'er is superior to a treatment #itout $eta%$lo&'er administration. e introdu&tion o(

 $eta%$lo&'ers sould) tere(ore) al#ays $e attempted even i( te titration period as to $e

 prolonged.

+eta%$lo&'ers may) o#ever) indu&e myo&ardial depression and pre&ipitate eart (ailure. In

addition) $eta%$lo&'ers may initiate or e9a&er$ate astma and indu&e periperal

vaso&onstri&tion. a$le , gives te re&ommended pro&edure (or te use o( $eta%$lo&'ers in

&lini&al pra&ti&e and teir &ontraindi&ations. a$le so#s te titration s&eme o( te drugs

used in most relevant studies.

 

Side Effects

+eta%$lo&'ers &an $e divided into t#o &lasses8

• non-selective beta-blockers #i& $lo&' $ot :, and : re&eptors in te eart) lungs

and around te $ody.

 

• cardio-selective beta-blockers #i& (o&us teir a&tivity on te eart. e use o(

tese &ardio%sele&tive $eta%$lo&'ers) su& as $isoprolol) &arvedilol) metoprolol and

ne$ivolol ave led to (e#er side e((e&ts) su& as $ron&o&onstri&tion) $ut oter side

e((e&ts) su& as depression) ere&tile dys(un&tion and &old periperies may still $e

e9perien&ed.

1verall) most people tolerate tem #ell $ut all patients $eing treated (or eart (ailure sould

 $e #arned a$out te ris' o( a temporary e9a&er$ation in symptoms a(ter starting on a $eta%

 $lo&'er.

 References

,. Le ;emtel H. Revie# o( te *ardia& Insu((i&ien&y +Isoprolol Study II 6*I+IS%II7. Curr

Cardiol Rep ,<<<= 16,78 <>!".

 

. Merit HF investigators. -((e&t o( metoprolol *R/?L in &roni& eart (ailure. Lancet ,<<<=

3356<,@<78 "",>"".

!. Flater MD) et al. Randomised trial to determine te e((e&t o( ne$ivolol on mortaility and

&ardiovas&ular ospital admission in elderly patients #it eart (ailure 6S-0I1RS7. Eur

 Heart J ""B= 266!78 ,B>B.

2. Cilleneimer R) et al . -((e&t on survival and ospitaliation o( initiating treatment (or

&roni& eart (ailure #it $isoprolol (ollo#ed $y enalapril) as &ompared #it te opposite

seEuen&e8 results o( te randomised &ardia& Insu((i&ien&y +isoprolol Study 6*I+IS7 III

Circulation ""B= 1126,@78 2@>2!B.