A103-12 Beta-blocker Continuation Versus Withdrawal in Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis

Rationale Beta-blocker therapy is a cornerstone of chronic heart failure management, yet its handling during acute decompensated heart failure (ADHF) remains controversial, with practice variation regarding continuation versus withdrawal. This systematic review and meta-analysis was conducted to synthesize the evidence and quantify the mortality risk associated with beta-blocker withdrawal during ADHF hospitalization. Methods Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane CENTRAL (inception through August 2025) for studies reporting mortality outcomes for beta-blocker continuation versus withdrawal in ADHF. We extracted 13 distinct effect estimates from 10 unique studies (n = 71,387 patients), including RCTs, large registries, and prospective cohort studies. A random-effects meta-analysis using the DerSimonian-Laird method was performed to calculate pooled effect sizes. Prespecified subgroup analyses by outcome timing, study design, and effect measure were conducted to explore heterogeneity. Results Our meta-analysis demonstrated that beta-blocker withdrawal was associated with significantly increased mortality (pooled effect estimate: 2.69, 95% CI: 1.86-3.87; p < 0.000001; I²=86.3%). Prespecified subgroup analyses demonstrated substantially reduced heterogeneity: hazard ratio studies showed no heterogeneity (pooled HR: 2.27, 95% CI: 1.83-2.81; I²=0.0%; n = 6), as did prospective cohort studies (pooled effect: 3.38, 95% CI: 2.20-5.18; I²=0.0%; n = 3). Analysis by outcome timing revealed: in-hospital mortality (effect estimate: 4.61, 95% CI: 2.15-9.85; I²=81.0%; n = 5), short-term mortality at 30-90 days (2.05, 95% CI: 1.35-3.11; I²=23.5%; n = 3), and long-term mortality ≥6 months (2.22, 95% CI: 1.73-2.84; I²=7.8%; n = 4). Conclusions This meta-analysis of over 71,000 patients provides robust evidence that beta-blocker withdrawal during ADHF hospitalization is associated with more than two-fold increased mortality risk. The consistency of effect across high-quality study designs (I²=0% for HR studies) and outcome timepoints supports a true treatment effect rather than confounding. These findings strongly support guideline recommendations to continue beta-blocker therapy in hemodynamically stable ADHF patients and highlight the need for prospective trials evaluating optimal dosing strategies during acute decompensation.