The favorable effects of beta-blockers were also observed in patients already taking ACE inhibitors, which suggests that combined blockade of 2 neurohormonal systems can produce additive effects.
Practical use of beta-blockers
Selection of patients
Beta-blockers should be prescribed without delay to all patients with stable HF due to left ventricular systolic dysfunction unless they have a contraindication to their use or have been shown to be unable to tolerate treatment with these drugs.
Beta-blockers should be also administered to patients with mild symptoms or clinically stable, because, despite offering only a minimal benefit in terms of symptom control, they certainly reduce the risk of disease progression, future clinical deterioration, and sudden death73.
In general, beta-blockers are used together with an ACE inhibitor, a diuretic and often digitalis.
Patients do not need to be taking high doses of ACE inhibitors before being considered for treatment with a beta-blocker, because most patients enrolled in the beta-blocker trials were not taking high doses of ACE inhibitors. Furthermore, in patients taking a low dose of an ACE inhibitor, the addition of a beta-blocker produces a greater improvement in symptoms and reduction in the risk of death than an increase in the dose of the ACE inhibitor74.
Beta-blockers should not be prescribed without diuretics in patients with a current or recent history of fluid retention, because diuretics are needed to maintain sodium balance and prevent the development of fluid retention that can accompany the initiation of beta- blocker therapy75.
As previously mentioned, beta-blockers should be only administered to patients with HF who are sufficiently stable. Candidates not eligible for immediate treatment with a beta- blocker are those hospitalized in an intensive care unit, those with evidence of fluid overload or volume depletion, and those who have required recent treatment with an intravenous positive inotropic agent. The patients excluded from treatment for these reasons should first receive intensified treatment with other drugs for HF (e.g., diuretics) and then be re-evaluated for beta-blockade after clinical stability has been achieved.
73 Colucci WS, Packer M, Bristow MR, et al. Carvedilol inhibits clinical progression in patients with mild symptoms of heart failure. US Carvedilol Heart Failure Study Group. Circulation 1996;94:2800-6.
74 Packer M, Poole-Wilson PA, Armstrong PW, et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group. Circulation 1999;100:2312-8.
75 Epstein SE, Braunwald E. The effect of beta adrenergic blockade on patterns of urinary sodium excretion: studies in normal subjects and in patients with heart disease. Ann Intern Med 1966;65:20-7.