Don't Halt Beta-Blockers During Acute Heart Failure

BARCELONA — The common practice of discontinuing beta-blocker therapy during hospitalization for an acute exacerbation of heart failure is counterproductive, according to a French randomized trial.

“During acute heart failure, beta-blocker therapy should be continued, because this practice is not associated with delayed or lesser improvement and there is a higher rate of chronic beta-blocker therapy 3 months later, the benefits of which are well established,” Dr. Guillaume Jondeau concluded in presenting the results of the Beta Blocker Continuation Versus Interruption in Patients With Congestive Heart Failure Hospitalized for a Decompensation Episode (B-CONVINCED) trial at the annual congress of the European Society of Cardiology.

B-CONVINCED was conducted to redress the lack of level 1 evidence regarding the best clinical strategy when patients with systolic dysfunction who are on chronic beta-blocker therapy are hospitalized for acute heart failure. Many physicians, reasoning that the acutely failing circulatory system needs adrenergic support, routinely halve the dose or halt the drug altogether. The 2008 ESC guidelines straddle the fence, stating as a class IIA recommendation that “a reduction in the beta-blocker dose may be necessary. In severe situations, temporary discontinuation can be considered.”

The primary end point in the 147-patient multicenter B-CONVINCED trial was improvement in both dyspnea and general well-being 3 days into the hospitalization. This was achieved in 93% of the beta-blocker continuation group and 92% of the drug-halt group. After 8 days, 95% of patients in both study arms were significantly improved. Duration of hospital stay, patient self-assessments, and rehospitalization rates during the next 3 months were similar in the two groups.

But 3 months after the acute exacerbation, the proportion of patients on beta-blocker therapy was 90% in the continuation group and 76% in the discontinuation group, a significant difference. Once beta-blocker therapy has been stopped, it can be a challenge to restart and titrate up effectively, observed Dr. Jondeau of the University of Paris.

Discussant Dr. Karl Swedberg noted that B-CONVINCED provides the first randomized clinical trial evidence that sticking to the prehospitalization beta-blocker dose during an acute heart failure exacerbation should be the first-line strategy, said Dr. Swedberg, professor of cardiology at Sahlgrenska University Hospital, Goteborg, Sweden.

B-CONVINCED was funded by the French Ministry of Health. Neither Dr. Jondeau nor Dr. Swedberg disclosed any relationships with industry.

Once beta-blocker therapy has been stopped, it can be a challenge to restart and titrate up effectively.

Source DR. JONDEAU