Beta-blockers: the new standard of therapy for mild heart failure.

Many physicians are reluctant to prescribe beta-blockers to patients with mild heart failure, especially when standard therapy (diuretics and an angiotensin-converting enzyme inhibitor, with or without digitalis glycosides) seems to be effective at relieving symptoms. However, current first-line medications for heart failure either ignore or incompletely inhibit adrenergic activation, one of the primary contributors to progressive left ventricular systolic dysfunction. Thus, even effective standard "triple" therapy does not safeguard the patient against further catastrophic deterioration of cardiac performance. Clinical trials have shown that the use of beta-blockers in addition to standard therapy improves left ventricular function, reduces hospitalizations, and-in the cases of bisoprolol, long-acting metoprolol, and carvedilol-improves survival in patients with chronic heart failure. In addition, carvedilol has been found to significantly slow disease progression even in mildly symptomatic patients. Though achieving beta-blockade in patients with heart failure requires extra effort by the clinician (appropriate patient selection, optimization of background therapy, initiating drug treatment at low doses, and titrating slowly with careful vigilance for early signs of clinical instability), the cost is small compared with the consequence of postponing adrenergic intervention. The educational objective of this article is to provide the primary care physician with a review of the current understanding of the pathophysiological characteristics underlying chronic systolic heart failure, the clinical benefits of administering beta-blockers during the early stages of heart failure, and the practical considerations of initiating therapy.