THE ROLE OF BETABLOCKER IN

HEART FAILURE
- PERSPECTIVE FROM COMORBIDITIES -

Rarsari Soerarso Pratikto

 Recent Guidelines on Heart Failure

The importance of
ACEi/ARBs/ARNI, Beta blocker, MRA,
and Ivabradine
 Neurohormonal imbalanced in HF is characterized by
sustained overactivation of RAAS and SNS with attenuation of
the effects of NPs
Balancing neurohormonal in heart failure
Elevated resting HR in cardiovascular disease
Comorbidities and heart failure
Survival Heart failure re-hospitalization

European Journal of Heart Failure (2014) 16, 103–111

 COMORBIDITIES in HF
o Anaemia o Liver dysfunction
o Stroke o Gout
o Angina o Hyperlipidemia
o Asthma & COPD o Hypertension
o Cachexia o Kidney dysfunction
o Cancer o Obesity
o Diabetes o Sleep disordered breathing
o Depression o Thyroid dysfunction
o GI problems o Erectile dysfunction
o Electrolyte imbalance o Arrhythmias
 Respiratory effect of beta-blockers in people with asthma and cardiovascular
disease: population-based nested case control study

Conclusions: Cardioselective beta-blockers prescribed to people

with asthma and CVD were not associated with a significantly
increased risk of moderate or severe asthma exacerbations and
potentially could be used more widely when strongly
indicated.

Morales et al. BMC Medicine (2017) 15:18

 Asthma (relative contra-indication): if cardio-selective beta-
blockers are indicated, asthma is not necessarily an absolute
contra-indication, but these medications should only be used
under close medical supervision by a specialist, with consideration
of the risks for and against their use;
COPD is not a contra-indication
 Beta-blockers in patients with asthma and COPD
A population list of 857 patients Conclusion
coded as having asthma and COPD
Spencer R, Serumaga B. Prescriber 19 February 2012.
• Avoiding beta-blockers in the majority
of patients with asthma – the difficulty
comes when there is an
overwhelming indication for a beta-
blocker
• Patients with cardiac failure and acute
MI have their lives prolonged by
beta-blocker treatment and all current
guidelines recommend their use.
• Cardioselective Beta-blockers :
Bisoprolol is unique in being almost
14 times more selective for beta1
(cardiac) than for beta2 receptors
(bronchial)
 COMORBIDITIES in HF
o Anaemia o Liver dysfunction
o Stroke o Gout
o Angina o Hyperlipidemia
o Asthma & COPD o Hypertension
o Cachexia o Kidney dysfunction
o Cancer o Obesity
o Diabetes o Sleep disordered breathing
o Depression o Thyroid dysfunction
o GI problems o Erectile dysfunction
o Electrolyte imbalance o Arrhythmias
 Beta blocker use in subjects with type 2 diabetes mellitus
and systolic heart failure does not worsen glycaemic control

BB use did not worsen glycaemic control, lipid profile or

albuminuria status in subjects with SHF and T2DM. Carvedilol
significantly improved glycemic control in subjects with SHF
and T2DM and this improvement was non significantly better
than that obtained with bisoprolol.
BB's should not be withheld from patients with T2DM and SHF.

Wai et al. Cardiovascular Diabetology 2012, 11:14

 High-Dose Beta-Blockers More Effective in
Chronic Heart Failure, Diabetes
Study Result - Conclusion

• 1797 patients with CHF, 530 • increasing beta blocker

T2DM
• 3 groups, each :
• Ramipril 2.5 - 10 mg +
bisoprolol 2.5 - 7.5 mg
• Ramipril 2.5 - 10 mg +
bisoprolol 2.5 mg
• Ramipril 2.5 – 10 mg, no BB
• 4 years follow up
Schad, V. Endocrinologyadvisor, Nov 2017
doses were associated with
lower all-cause mortality in
patients with and without
diabetes
• the magnitude of this
association was significantly
greater in patients with
diabetes
 Treatment of heart failure in patients with type 2 diabetes mellitus

Beta-blockers in patients with T2DM and HF lead to significant

improvements in morbidity and mortality that are consistent with results in
patients without T2DM. These treatment benefits of beta-blockers in
diabetic patients far outweigh the theoretical risks related to
hypoglycaemia and minor changes in HbA1c and serum lipids. These benefits
strongly support beta-blocker treatment in patients with concurrent T2DM
and HF.
 COMORBIDITIES in HF
o Anaemia o Liver dysfunction
o Stroke o Gout
o Angina o Hyperlipidemia
o Asthma & COPD o Hypertension
o Cachexia o Kidney dysfunction
o Cancer o Obesity
o Diabetes o Sleep disordered breathing
o Depression o Thyroid dysfunction
o GI problems o Erectile dysfunction
o Electrolyte imbalance o Arrhythmias
 Hypertension
(with compelling indications)

Beta blocker is useful as treatment

in hypertension with various
compelling indications, including
pregnancy
ESC 2013, JNC VIII
 COMORBIDITIES in HF
o Anaemia o Liver dysfunction
o Stroke o Gout
o Angina o Hyperlipidemia
o Asthma & COPD o Hypertension
o Cachexia o Kidney dysfunction
o Cancer o Obesity
o Diabetes o Sleep disordered breathing
o Depression o Thyroid dysfunction
o GI problems o Erectile dysfunction
o Electrolyte imbalance o Arrhythmias
Thyroid function in heart failure and impact on mortality

Mitchell JE, Hellkamp AS, Mark DB, et all. JACC, 2013

 The interaction between thyroid hormones and
cardiovascular system

ACEi/ARB
β-blocker
Recent Guidelines on Heart Failure

The importance of
Comorbidities – underlying causes
(incl. Thyroid disorders)
 COMORBIDITIES in HF
o Anaemia o Liver dysfunction
o Stroke o Gout
o Angina o Hyperlipidemia
o Asthma & COPD o Hypertension
o Cachexia o Kidney dysfunction
o Cancer o Obesity
o Diabetes o Sleep disordered breathing
o Depression o Thyroid dysfunction
o GI problems o Erectile dysfunction
o Electrolyte imbalance o Arrhythmias – atrial fibrillation
 CONCLUSION: Based on the potential risks and benefits, as well as the
presence of alternative drugs, there is a limited role for digoxin in the
management of patients with normal sinus rhythm and congestive heart
failure. Based on the retrospective studies reviewed there is a growing
volume of data showing increased mortality in those with only atrial
fibrillation. The proper role of digoxin is, however, less certain in other
subgroups of patients, such as those with both atrial fibrillation and systolic
congestive heart failure or after a myocardial infarction.
 Beta-Blockers Or Digoxin For
Atrial Fibrillation And Heart Failure?
- A Review -
Conclusion
• Rate control therapy most often includes a beta-blocker,
• Digoxin is mainly given to elderly AF patients with HF ; Consequently,
its use is associated with increased crude rates of mortality
• it is unclear whether digoxin has a clear independent association with
increased mortality.
• it should be reserved for rate control in AF patients who are sedentary
or who have left ventricular systolic dysfunction, particularly when
beta-blockers do not achieve sufficient rate control and when they are
poorly tolerated or contraindicated.

Fauchier, L, et al. Cardiac Failure Review 2016;2(1):35–9

Recommendations for initial management of a rapid ventricular rate in patients
with heart failure and atrial fibrillation in the acute or chronic setting (ESC 2016)

For patients in NYHA Class I–III, a beta-

blocker, usually given orally, is safe and
therefore is recommended as first line
treatment to control rate, provided the
patient is euvolaemic
(I A)
Antiarrhythmic Effect of Bisoprolol, a Highly Selective β1-Blocker,
in Patients With Paroxysmal Atrial Fibrillation
The results demonstrate that
bisoprolol has an antiarrhythmic
effect against sympathetic diurnal
P-AF, improving subjective
symptoms and QOL and
eliminating P-AF episodes in
ECGs.
(Ishiguro H, et al. Int Heart J
2008; 49: 281-293)
 Safety and tolerability of beta-blockers:
prejudices and reality
CONCLUSION
• COPD/ asthma
• Beta-blockers appear to have a very low rate
• Peripheral artery disease of drug-related adverse events.
• T2DM
• Central nervous system • Patients with COPD, diabetes, peripheral
vascular disease, and the elderly can be
• Erectile dysfunction prescribed beta-blockers, provided
• Elderly appropriate precautions are taken.

• Most side-effects are consequences of beta-

Double-blind studies in CHF and post-MI
blockade, and are thus dose-dependent. A
policy of ‘start low and go slow’ can
therefore often avoid problems.

No reason why they • should

ED is no more common with beta-blockers
notother
than with any take
druga
prescribed for CHF
potentially life-saving treatment.
or hypertension.

Erdmann E, European Heart Journal Supplements, Volume 11, Issue suppl_A, March 2009, Pages A21–A25
 The importance of HR in CVD
(Betablokers : Beyond HR reducer)
Which beta blocker ?
ESC Guidelines on HF 2016
Canadian Guidelines on HF 2017

ACC/ AHA Guidelines on HF 2017

Conclusion
Beta-blockers are one of four medicines highly recommended for
systolic HF, has been shown to :
• Improve the percentage of blood pumped from the left ventricle with
each heartbeat (ejection fraction).
• Reduce the need for hospital stays.
• Slow the progression of heart failure.
• Reduce the risk of death caused by heart attack and heart failure.

The benefits of this medicine are more important

than any minor side effects.
THANK YOU