Achieving a Maximally Tolerated β-Blocker Dose in Heart Failure Patients: Is There Room for Improvement?

Heart failure (HF) is associated with significant morbidity and mortality. Although initially thought to be harmful in HF, beta-adrenergic blockers (β-blockers) have consistently been shown to reduce mortality and HF hospitalization in chronic HF with reduced ejection fraction. Proposed mechanisms i...

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Bibliographic Details
Published in:	Journal of the American College of Cardiology Vol. 69; no. 20; pp. 2542 - 2550
Main Authors:	Bhatt, Ankeet S, DeVore, Adam D, DeWald, Tracy A, Swedberg, Karl, Mentz, Robert J
Format:	Journal Article
Language:	English
Published:	United States Elsevier Limited 23-05-2017
Subjects:	Activation Adrenergic beta-Antagonists - administration & dosage Adrenergic beta-Antagonists - classification Adrenergic beta-Antagonists - pharmacokinetics Adrenergic receptors Affinity Aldosterone Algorithms Angiotensin Antagonists association hfa Attenuation Beta blockers beta-antagonists Biological effects Blood pressure Cancer Cardiac and Cardiovascular Systems Cardiology Cardiovascular disease Cardiovascular diseases Cardiovascular pathology carvedilol Chemical compounds chronic heart failure Clinical trials Computer programs Congestive heart failure Coronary artery Coronary artery disease Cytochrome Cytochrome P450 Death Diabetes mellitus Dosage Dose-Response Relationship, Drug dosing Drug dosages Drug therapy Drugs elderly-patients european-society Genetic diversity Genetic variance Guidelines Health risks Heart failure Heart Failure - drug therapy Heart Failure - physiopathology Heart rate Heart Rate - drug effects Humans Hypertension Insulin Intervention Kardiologi Maximum Tolerated Dose Morbidity Mortality Nervous system Nitric oxide Optimization optimize-hf outcomes Peptides Pharmacology Prostaglandins randomized controlled-trial Receiving Receptors (physiology) Reduction Risk factors Side effects Sinus Sympathetic nervous system task-force Titration Treatment Outcome Ventricle heart rate chronic heart failure beta-antagonists dosing
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Summary:	Heart failure (HF) is associated with significant morbidity and mortality. Although initially thought to be harmful in HF, beta-adrenergic blockers (β-blockers) have consistently been shown to reduce mortality and HF hospitalization in chronic HF with reduced ejection fraction. Proposed mechanisms include neurohormonal blockade and heart rate reduction. A new therapeutic agent now exists to target further heart rate lowering in patients who have been stable on a "maximally tolerated β-blocker dose," but this definition and how to achieve it are incompletely understood. In this review, the authors summarize published reports on the mechanisms by which β-blockers improve clinical outcomes. The authors describe differences in doses achieved in landmark clinical trials and those observed in routine clinical practice. They further discuss reasons for intolerance and the evidence behind using β-blocker dose and heart rate as therapeutic targets. Finally, the authors offer recommendations for clinicians actively initiating and up-titrating β-blockers that may aid in achieving maximally tolerated doses.
Bibliography:	ObjectType-Article-2 SourceType-Scholarly Journals-1 ObjectType-Feature-3 content type line 23 ObjectType-Review-1
ISSN:	0735-1097 1558-3597
DOI:	10.1016/j.jacc.2017.03.563