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Potential Harms of Interrupting Beta-Blocker Therapy in Acute Decompensated Heart Failure
Study Questions:
What are the effects of beta-blocker withdrawal in acute decompensated heart failure (ADHF)?
Methods:
This was a meta-analysis of relevant studies from January 2000 through January 2015. Eligible studies met the following inclusion criteria: 1) Randomized controlled trial or observational study; 2) compared continuation and withdrawal of beta-blockers; 3) reported at least one of the outcomes of in-hospital mortality, rehospitalization, and death rates in short-term (≤6 months after index hospitalization); and 4) reported the relative risk (RR) with its corresponding 95% confidence interval (CI) or sufficient data to calculate these measures.
Results:
Final analysis was conducted from one randomized clinical trial and five observational studies. There were 2,155 patients that continued beta-blocker therapy and 399 patients that discontinued beta-blocker therapy. Discontinuation of beta-blocker was associated with significantly increased risk of in-hospital mortality (RR, 3.72; 95% CI, 1.51-9.14). Discontinuation of beta-blocker was associated with increased short-term mortality (RR, 1.61; 95% CI, 1.04-2.79) and combined short-term rehospitalization or death (RR, 1.59; 95% CI, 1.03-2.45). Two studies examined the effects of beta-blocker withdrawal in patients treated with inotropes. Discontinuation of beta-blockade in milrinone-treated patients was associated with an odds ratio of 6.48 (95% CI, 1.75-23.98) for death at 60 days. The effects of beta-blocker withdrawal in patients treated with either dobutamine or levosimendan showed a nonsignificant reduction in risk of death at 31 days and 180 days.
Conclusions:
Discontinuation of beta-blocker therapy in patients admitted with ADHF may be associated with significantly increased risk of in-hospital mortality, short-term mortality, and the combined endpoint of short-term rehospitalization or mortality.
Perspective:
Although beta-blocker therapy unquestionably reduces mortality in patients with chronic HF with reduced ejection fraction, there is less certainty about the role of beta-blocker therapy in patients with ADHF. Although concerns about the negative inotropic effects of beta-blockers may offer a compelling reason to stop these medications in patients with ADHF, the study authors offer evidence about the potentially deleterious effects of beta-blocker withdrawal in ADHF. Certainly there are limitations to this meta-analysis, and the reported CIs are large. As the authors posit, the mechanism through which the continuation of beta-blocker may improve short-term outcomes may be related to the increased beta-blocker use following rehospitalization. While clinical judgment should continue to guide the decision to continue (or withdraw) beta-blocker therapy, there may be circumstances in which it is beneficial to not interrupt beta-blockade, as in patients treated with milrinone.
Keywords: Adrenergic beta-Antagonists, Dobutamine, Heart Failure, Hospital Mortality, Hydrazones, Milrinone, Pyridazines, Risk
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