Practical aspects of using beta-adrenergic blockade in systolic heart failure

Abstract

Heart failure exacts a severe human and public health toll. In the United States, heart failure afflicts approximately 5 million patients and is responsible for or contributes to 3 million hospitalizations and 300,000 deaths yearly. Physicians can have a major impact on this disease by using effective agents for the treatment of heart failure (particularly angiotensin-converting enzyme [ACE] inhibitors and β blockers), yet the actual clinical use of these drugs (especially the use of β blockers by primary physicians) is disappointingly low. Many physicians appear to be reluctant to prescribe β blockers for two reasons. First, they are concerned about the potential interference of β blockers with important compensatory mechanisms that support the failing heart and fear that such interference may lead to clinical deterioration. Second, they fail to identify patients with heart failure (especially those with mild or moderate symptoms) or regard such patients as being too well to require additional treatment. These reasons should no longer be used as excuses to avoid the use of these drugs, given the persuasive evidence that β blockers can improve symptoms and prolong life in patients with heart failure. Instead, physicians must recognize that long-term activation of the sympathetic nervous system primarily exerts deleterious (rather than compensatory) effects in patients with heart failure and that these actions can be antagonized effectively and safely by the appropriate use of β-blocking drugs.