Beta-blocker management in patients admitted for acute heart failure and reduced ejection fraction: a review and expert consensus opinion

Figure 1. The physiologic and pathophysiologic role of the beta-adrenergic pathway. The role of beta-adrenergic stimulation in cardiac physiology is pivotal (white circles). Intense and sustained stimulation (dotted arrow) are presumed to be responsible for the deleterious effects observed in patients with severe heart failure (gray circles).

Figure 2. Pharmacological properties of the different beta-blocker generations. Second and third generations show a greater β1 selectivity and, for third generation compounds, an additional vasodilatory activity. Acute hemodynamic effects reveal a safer profile with carvedilol (as compared to others) regarding cardiac index and systemic vascular resistances. PCWP, pulmonary capillary wedge pressure; SVR, systemic vascular resistance.

Figure 3. BB management in acute decompensated HF. This schematic overview of BB in AHF highlights the crucial role of accurate patient's hemodynamic condition assessment and its management for clinician decision making. “Facilitated” initiation strategies may be considered for the most severe patients. ACS, acute coronary syndrome; BB, beta-blocker; HF, heart failure; HT, heart transplantation; LVAD, left ventricular assist device; MCS, mechanical circulatory support; PDEI, phosphodiesterase inhibitor; RHC, right heart catheterization; RV, right ventricle; SCAI, Society of cardiovascular angiography and intervention; SGLT2I, sodium-glucose cotransporter 2 inhibitors; TTE, transthoracic echocardiography.

Figure 4. Practical considerations for BB introduction in patients with AHF. To minimize treatment failure and improve tolerance, introduction should only be considered after a multi-parameter evaluation, especially for congestion and perfusion status. ACEI, angiotensine converting enzyme inhibitor; BP, blood pressure; CO, cardiac output; CRT, capillary refill time; CVP, central venous pressure; HR, heart rate; IVC, inferior vena cava; MAP, mean arterial pressure; RHC, right heart catheterization; RV, right ventricle; RVFAC, right ventricular fractional area change; TAPSE, tricuspid annular plane systolic excursion; TTE, transthoracic echocardiography.