beta-Blocker therapy in heart failure

Heart failure is an important public health problem and one for which morbidity and mortality remain high despite treatment with angiotensin converting enzyme (ACE) inhibitors. A large number of clinical trials examining the effects of beta-blockers in the treatment of heart failure have now been performed. Two large-scale clinical trials have recently confirmed significant survival benefits with these agents, with effects that are additive to those achieved with ACE inhibitor therapy. These trials have now established beta-blocker therapy as an important part of standard heart failure treatment. The clinical use of beta-blockers in patients with heart failure requires careful translation of the randomized controlled trials into everyday clinical practice. Patient selection is key to the safe use of beta-blockers. Patients who may be suitable for beta-blockade therapy include those with mild-moderate heart failure due to left ventricular systolic impairment, those who are receiving adequate dose of diuretics and ACE inhibitors and those whose clinical condition is stable at the time of initiation of the beta-blocker. Survival benefits have been demonstrated with bisoprolol, carvedilol and metoprolol. Whether different beta-blockers have important clinical differences with regard to clinical end-points is as yet uncertain. beta-Blockers should be initiated at low dose, with titration of dose over several weeks and careful clinical monitoring for potential adverse effects, such as hypotension or worsening congestion. This careful application of the clinical trials into clinical practice will allow the safe use of this effective treatment for patients with chronic heart failure.