Beta-Blockers, Clinical Evidence

Multiple studies have found decreased mortality and hospitalization rates with the use of beta-blockers in adults with chronic heart failure. [Bristow: 1996] [Packer: 1996] [MERIT-HF: 1999] [CIBIS-II: 1999] A dose-dependent increase in left-ventricular ejection fraction has been reported. [Bristow: 1996]

Until recently, beta-blockers were recommended only for the treatment of mild to moderate heart failure in adults. However, the recent Carvedilol Prospective Randomized Cumulative Survival Trial (COPERNICUS) found a 35% reduction in all-cause mortality in adults with severe heart failure symptoms who had received carvedilol. [Packer: 2001] Although the mechanism of action of beta-blockers in heart failure is still being defined, a large body of basic and clinical investigation indicates that their major benefit is prevention or reversal of the myocardial dysfunction that occurs because of sympathetic activation, primarily from norepinephrine.[Bristow: 1997]

The effects of beta-blockers in children with heart failure is entirely anecdotal. There are reports of the efficacy of metoprolol in small groups of children with cardiomyopathy. [Shaddy: 1995] [Shaddy: 1998] [Shaddy: 1999] A multicenter retrospective report of carvedilol in children has also suggested a potential benefit in improved ventricular performance and symptoms. [Bruns: 2001] However, as of yet no prospective randomized trials of beta-blockers in children have been completed that could clearly define safety and efficacy. A meta-analysis found mixed results in studies investigating the effects of beta-blockers on CHF in children, although the studies were notably heterogeneous in terms of beta-blocking agent and doses used, patient age, and nature of cardiac condition. [Frobel: 2009] The authors concluded insufficient evidence exists to recommend or discourage the use of these medications in the pediatric population.

Buchhorn et al., has reported the beneficial effects of propranolol in infants with congestive heart failure from left-to-right intracardiac shunts. [Buchhorn: 2001] [Buchhorn: 1998] In these studies, treatment with propranolol resulted in lower respiratory rates and heart rates, and improved weight gain. There were also significant changes in circulating neurohormonal parameters. These effects of propranolol seem to be better than those seen with low-dose captopril. [Buchhorn: 2000] Thus, there may be some benefit of beta-blockers in this clinical setting, although further study is indicated.

Beta-blockers are currently recommended for adults with stable NYHA class II or III heart failure caused by left ventricular systolic dysfunction, unless they are unable to tolerate treatment or have a contraindication to use of these drugs. [Packer: 1999] The dosing of beta-blockers differs for each agent, but all beta-blockers are initiated at a very low dose and increased slowly over several weeks while the patient is carefully monitored for adverse effects. Children who receive carvedilol for the treatment of heart failure have a high incidence of adverse effects. [Bruns: 2001] These medications need to be used with caution and patients monitored closely. Dosing in children has been extrapolated from adult data, and thus the ideal dosing schedules for beta-blockers in children with heart failure are unknown.


Helpful Articles

Madriago E, Silberbach M.
Heart failure in infants and children.
Pediatr Rev. 2010;31(1):4-12. PubMed abstract

Kay JD, Colan SD, Graham TP Jr.
Congestive heart failure in pediatric patients.
Am Heart J. 2001;142(5):923-8. PubMed abstract

Authors & Reviewers

Initial publication: July 2010; last update/revision: October 2014
Current Authors and Reviewers:
Author: Medical Home Team

Page Bibliography

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