Ensure Adequate Titration of β-Blockers for Optimal Clinical Outcomes in Heart Failure

Research recently published in Current Medical Research and Opinion demonstrates that higher doses of β-blockers are associated with better clinical outcomes in patient with heart failure (HF). Adequate titration of these therapies to maximally tolerated doses is important for achieving optimal outcomes in individuals with HF, and pharmacists can play a crucial role.

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The goals of pharmacologic therapy for HF are to prevent hospitalization for HF, to improve functional status and quality of life, and to prolong life. Moreover, many experts in HF management now recommend that the pharmacologic management of HF should focus primarily on addressing the signs, symptoms, and severity of HF (e.g. tachycardia, edema).

Therefore, it is rational to prescribe a 4-drug combination including a β-blocker, a renin-angiotensin-aldosterone system (RAAS) inhibitor (e.g. angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or angiotensin receptor-neprilysin inhibitor), a mineralocorticoid receptor antagonist, and a sodium glucose co-transporter-2 inhibitor for a patient with HF. Importantly, doses of these drugs should be up-titrated either to the dose used in the outcomes trials that defined their clinical benefits or to the maximally tolerated dose. Moreover, a loop diuretic should be added if needed to control fluid retention.

Research findings have shown that patients with HF who had optimal titration of RAAS blocker and β-blocker combination therapies fared better than those did not. Furthermore, a higher dose of β-blockers was also associated with a better outcome compared with medium- or low-effect doses in 5242 patients with HF. Moreover, a study based on 36,168 patients with HF found that a high vs. low dose of a β-blocker predicted a lower mortality rate.

Therefore, adequate titration of doses of guideline-directed medical therapies is crucial. It is also important to conduct close monitoring of heart rate, blood pressure, and symptoms of worsening heart failure during the titration phase. Moreover, consider gradual dose reduction in case of tolerability issues. It may be necessary to reduce the dose in the event of heart failure, hypotension, or bradycardia, but clinicians should consider restoring the previous dose if or when the patient becomes stable. If withdrawal of treatment is necessary, do so gradually with a tapered dose.

Nevertheless, evidence persists that β-blockers are underused or underdosed in individuals with HF. Ensuring the inclusion of a β-blocker within the regimen of individuals with HF, with adequate titration of therapy to the doses used in clinical outcomes trials (or to the maximally tolerated doses), remains important for ensuring optimal outcomes for patients with HF.

REFERENCE

De Oliveira Jr MT, Baptista R, Chavez-Leal SA, Bonatto MG, et al. Heart failure management with β-blockers: can we do better? Curr Med Res Opin. 2024;40(sup1)43-54. doi:10.1080/03007995.2024.2318002