Beta-blockers in Heart Failure

What are beta-blockers?

Beta-blockers are a class of medications used to treat high blood pressure and heart failure. They are also given to women who have had a heart attack to prevent future heart problems. Beta-blockers slow the heart rate and decrease the strength of each heartbeat. This lowers your blood pressure and lessens the stress on your heart, slowing the progression of heart failure and improving survival.

Beta-blockers
Generic Names: Carvedilol / Metoprolol / Atenolol / Bisprolol / Propranolol / Timolol
Brand Names: Coreg / Lopressor, Toprol XL / Tenormin / Zebeta / Inderal / Blocadren
How it is given: Oral (tablet or capsule), intravenous (IV)
What it is used for:
  • Relief of symptoms and improved survival in patients with heart failure
  • Treatment of high blood pressure
  • After a heart attack to improve survival
  • Treatment of fast heart rhythms (tachyarrhythmias)
You should not be treated with it if: You have unstable heart failure (your heart failure symptoms worsen and you require hospitalization and/or you require intravenous medications to make your heart pump harder)

You should be started carefully on beta-blockers if you have:

  • a slow heart rate
  • low blood pressure
  • 2nd or 3rd degree heart block (your heart has problems sending signals from the top part to the bottom part of your heart)
  • a history of severe chronic obstructive lung disease (COPD) or asthma (some beta-blockers)
  • severe peripheral vascular disease
Pregnancy/nursing: Discuss the risks and benefits of this medication with your doctor if you are planning to become pregnant. Pregnant women should not take atenolol because it can harm the fetus. The safety of the other beta-blockers during pregnancy is not known. Women who are nursing should only take beta-blocksers if the potential benefit clearly outweights the risks to the baby – discuss these with your doctor.

What are they used for?

Beta-blockers are one of the first medications given to a woman with systolic heart failure, even if she has not started having heart failure symptoms yet. In women with heart failure, beta-blockers relieve heart failure symptoms, improve your ability to perform basic daily tasks, and slow the progression of the disease. Women who are treated with beta-blockers require fewer hospital stays and live longer.

Who should receive beta-blockers to prevent or treat heart failure?

Women who have been diagnosed with heart failure, whether or not they have started having symptoms, benefit from treatment with beta-blockers to slow the progression of the disease and improve survival. In women who are at high risk of developing heart failure, beta-blockers can be used to help control high blood pressure and delay the onset of heart failure.

In women with systolic heart failure who do not yet have heart failure symptoms, treatment with beta-blockers results in improved heart function (as measured by ejection fraction) and improved survival. Beta-blockers also slow down the changes that occur in the heart during heart failure. By improving the heart’s function and slowing down the heart’s structural changes, beta-blockers delay the progression of heart failure and the onset of symptoms.

For women with blood pumping problems (systolic heart failure) who already have symptoms of heart failure, beta-blockers improve the heart’s pumping ability and relieve heart failure symptoms, maing it easier to perform basic physical tasks. They also reduce hospital stays, and improve survival. A trial of 3991 patients (23% were women) with mild to severe heart failure found that adding a beta-blockers to standard heart failure treatment increased one-year survival by 34%. While women appeared to benefit to the same degree as men, the number of women in the study was too small to be certain.

The benefits of beta-blocker therapy in patients with diastolic heart failure (blood filling problems) are not as well defined. Beta-blockers can be used in women with diastolic heart failure to decrease blood pressure and may help to relieve heart failure symptoms. By slowing down your heart rate, beta-blockers give your heart more time to fill with blood. Lowering blood pressure may also help to relieve ventricular hypertrophy, thickening of the pumping chamber walls that happens in some women with blood filling problems.

Who should NOT receive beta-blockers?

Women with heart failure symptoms that change suddenly, requiring hospitalization or intravenous medications, should not start beta-blockers because it can make symptoms worse.20 Beta-blockers should be started carefully and slowly if you have severe lung disease or asthma, disease in the blood vessels of your legs (peripheral vascular disease), a slow heart rate (less than 60 beats per minute), low blood pressure, or if your heart has difficulty transmitting electrical signals (called heart block).20

Talk to your doctor about the risks and benefits of these medications if you are pregnant, nursing, or planning to become pregnant. Pregnant women should not take atenolol because it can harm the fetus, and the safety of the other beta-blockers during pregnancy is not known. Women who are nursing should not take beta-blockers; if the treatment is essential, then nursing should be discontinued.

How do beta-blockers work?

In heart failure, your heart has difficulty pumping enough blood to the rest of your body. As a result, your body’s nervous system sends signals to your heart to pump harder and faster in an attempt to get more blood to your vital organs. In the short term, this adjustment works. In the long term, the overworked heart muscle gradually suffers damage, and will eventually no longer be able to meet the body’s demands.

Beta-blockers prevent or slow this long-term damage by blocking the signals that tell your heart to speed up, effectively slowing your heart rate and decreasing the strength of the heart muscle’s contractions. Because blood is being pushed through the vessels with less force, the medication also lowers your blood pressure.

Do beta-blockers work as well in women as in men?

Yes. Although women typically make up only 20% to 30% of subjects in the major trials, when data from many studies is combined researchers generally find that women benefit from treatment with beta-blockers. Among 898 women in one trial, women taking beta blockers had 42% fewer stays in the hospital for heart failure and 21% fewer deaths or hospitalizations compared to women taking placebos. When data from five of the largest studies of beta-blocker studies were combined, women and men had similar survival improvements when they took beta-blockers. Studies have also shown that beta blockers improve the heart’s pumping ability in women.

Are women missing out on beta-blocker therapy?

Despite studies demonstrating that women with heart failure benefit from beta-blocker therapy, several studies have found that women are slightly less likely to be prescribed beta-blockers compared with men.  For example, one large study looked at the medical records of 105,388 patients and found that significantly fewer women were prescribed beta-blockers compared to men (55% vs. 58%). The reason for this modest gender difference in treatment is not clear.

Are beta-blockers as effective in African-Americans with heart failure?

In most cases, beta-blockers are just as effective in African Americans as in whites. However, race may affect the benefits received from specific types of beta-blockers. A report that combined data looking at a specific beta-blocker called carvedilol found that both blacks and non-black patients had the same benefit from beta-blocker use. However, unequal benefits were found in a trial with 2708 patients with moderate to severe heart failure (NYHA class III or IV) that looked specifically at bucindolol, another beta-blocker medication. Although deaths from cardiac problems were less common overall in the group of patients taking the beta-blocker, African-American patients did not benefit from this specific drug. Although different beta-blockers work in slightly different ways, it is not well understood why a patients of a certain race would respond better to one beta-blocker than another.

What are the side effects of beta-blockers?

Beta-blockers are usually well-tolerated medications. In fact, studies have found that patients were no more likely to stop taking beta-blockers because of side effects than they were to stop taking sugar pills. However, many experience fatigue that improves with time, and patients with a history of depression can become more depressed while taking beta-blockers.

Beta-blockers lower your heart rate, but most women do not notice this change during normal activities. You may feel less able to perform strenuous activities that would normally raise your heart rate, such as running, and become tired more easily when exercising. Dizziness is a relatively common side effect that may also be caused by a slow heart rate or by low blood pressure. However, this is rarely severe enough to require stopping treatment.

In the past, beta-blockers were usually not given to patients with peripheral vascular disease because they could cause symptoms of the disease to get worse, such as cold hands and get and pain in the legs after exercise. However, recent studies indicate that for most women with peripheral vascular disease, beta-blockers do not significantly affect walking capacity, leg pain symptoms, or skin circulation, and they have the benefit of improving survival.

In some women with asthma or chronic obstructive lung disease, certain beta blockers (metoprolol, bispoprol) can worsen breathing problems. However, most patients with lung disease do not have airways that are sensitive enough to be affected by other beta-blockers, and studies have found that in general patients with lung disease tolerate beta-blockers as well as patients without lung disease.

If I cannot take a beta-blocker, what are some alternatives?

There are several different types of beta-blockers that work in slightly different ways. If you are experiencing side effects, switching to a different type of beta-blocker often resolves the problem. Depending on why you are unable to take a beta-blocker, your doctor may want to decrease the dosage of your beta-blocker or try switching you to a different beta-blocker medication before completely stopping beta-blocker treatment.

My doctor has prescribed a beta-blocker. What should I watch out for?

While taking a beta-blocker, it is important to closely follow the doses prescribed to you. Beta-blockers decrease your heartbeat’s strength, so your heart failure symptoms may get worse when first starting the drug. To avoid this, your doctor may start you on a lower dosage and then slowly increase the dosage with time if you are able to handle it. Let your doctor know if your symptoms get worse; she or he can lower your dose of beta-blockers or increase the dose of other medications to control symptoms. Do not stop your beta-blocker medication on your own because stopping suddenly can make your symptoms worse.

If you experience any other side effects while taking beta-blockers, such as dizziness, headaches, nausea, excess tiredness with exercise, or worsening of your symptoms of lung disease, asthma, or peripheral vascular disease, let your physician know. She or he may be able to minimize these side effects by adjusting your dose or switching you to a different type of beta-blocker.

Beta-blockers may interact poorly with some other types of medications called calcium-channel blockers (for example verapamil or diltiazem). If you are already taking any of this class of medication, be sure to talk to your doctor about any precautions you should take or symptoms you should mindful of.

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