The paradigm to overcome in acute decompensated heart failure

We read with interest the article published by Ockerberg et al.1 For several decades, there has been an ongoing debate regarding the use of β-blockers in acute decompensated heart failure (ADHF) related to the adverse inotropic effects they exert; however, the results of the studies published to date seem to favor their use. Today, we know that the efficacy of β-blockers depends on ejection fraction and rhythm,2 and it is essential not to limit their use in patients with heart failure with reduced ejection fraction (HFrEF), especially in those with previous treatment.2 Interruption of β-blockers in acute heart failure has been associated with higher mortality, and initiation of positive inotropic agents does not justify their discontinuation.2,3 The concomitant presence of atrial fibrillation in the context of heart failure negatively affects morbidity and mortality;4 HFrEF is the only condition in which the evidence for the use of β-blockers is irrefutable,4 as suppression of sinus frequency in patients with reduced ejection fraction is also associated with unfavorable prognosis and increased risk of atrial fibrillation, according to published results from the SIGNIFY trial.4,5 This effect was associated with increased diastolic filling time and atrial and left ventricular wall stress.5 In this scenario, use of ultra-short-acting β-blockers (eg, esmolol and landiolol) is effective in suppressing sympathetic activity without a markedly deleterious effect on blood pressure and heart rate or patient hemodynamics, especially in the setting of ADHF, and the associated events do not appear to be dose dependent.6-10