with permission from http://medstat.med.utah.edu/WebPath/CVHTML/CV101.html

Confused? Well, you are not alone. Most of us learned that beta-blockers are potent negative inotropes which are contraindicated in patients with congestive heart failure. And yet, beta-blockers are now assumed by many to be a standard of care for patients with CHF. What happened? Until recently, the increase in sympathetic tone seen in patients with congestive heart failure was assumed to be of benefit. It is now clear that, while useful in the short term, this sympathetic activation is actually detrimental in the long run. The case for the use of beta-blockers really began in 1975 with the publication of a small trial of metoprolol in patients with congestive cardiomyopathy.1 Both clinical improvement and an decrease in left ventricular filling pressures were noted. Since that time, a series of trials with a variety of beta-blockers have demonstrated a salutary effect. (Table 1)

Table 1

Beta-blockers can worsen symptoms in patients with congestive heart failure. An abrupt reduction in sympathetic tone appears to be the culprit. Slow upward titration of dose rather than the initiation of therapy at full dose is usually sufficient to prevent worsening of symptoms.

Here are some suggestions for the use of beta-blockers in patients with CHF:

• Beta-blocker therapy should usually be initiated only after conventional therapies.

-diuretics

-digoxin

-ACE inhibitors

• Beta-blockers should be used with great caution, if at all, in CHF patients with hypotension or bradycardia.
  
  

• Start with a low dose and titrate according to clinical findings

-Metoprolol 6.25mg BID or Carvedilol 3.125mg BID  (If you use carvedilol, check the digoxin serum level after each dose adjustment)

-Titrate dose every 2-4 weeks based on patient symptoms

• The relative role of beta-blockers and spironolactone¹⁰ in addition to conventional therapy is unclear at the moment.

References:

1. Waagstein F, Hjalmarson A, Varnauskas E, et al. Effect of chronic beta-adrenergic receptor blockade in congestive cardiomyopathy. Br Heart J 1975;37(10):1022-1036.
2. Waagstein F. Bristow MR. Swedberg K, et al. Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Metoprolol in Dilated Cardiomyopathy (MDC) Trial Study Group. Lancet 1993;342(8885):1441-6.
3. Hjalmarson A, Goldstein S, Fagerberg B et al. Effects of controlled-release metoprolol on total mortality, hospitalizations and well-being in patients with heart failure: The Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF). JAMA 2000;283:1295-1302.
4. CIBIS Investigators and Committees. Congestive Heart Failure/LVH: A randomized trial of beta blockade in heart failure: The Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation 1994;90:1765-73.
5. CIBIS Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999;353:9-13.
6. Packer M Colucci WS, Sackner-Bernstein J, et al. Double-blind placebo-controlled study of the effects of carvedilol in patients with moderate to severe heart failure: The PRECISE Trial. Circulation 1996;94:2793-99.
7. Bristow MR, Gilbert EM, Abraham WT, et al. Congestive heart failure/myocardial disease: carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure. Circulation 1996;94(11):2807-2816.
8. Colucci WS, Packer M, Bristow MR, et al. Congestive heart failure/myocardial disease: carvedilol inhibits clinical progression in patients with mild symptoms of heart failure. Circulation 1996;94(11):2800-2806.
9. Cohn JN, Fowler MB Bristow MR et al. Safety and efficacy of carvedilol in severe heart failure. The US Carvedilol Heart Failure Study. J Card Fail 1997;3(3):173-179.
10. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341:709-17.