When to initiate beta-blockers in heart failure: is it ever too early?

Overwhelming clinical trial evidence confirms the efficacy and safety of beta-blockers in patients with heart failure (HF) caused by systolic dysfunction. beta-Blockers are recommended in national HF guidelines as standard of care therapy. Yet there is also a large body of evidence demonstrating that the use of beta-blockers for HF is seriously inadequate under conventional care. This HF treatment gap is due, in part, to the persistence of perceptions--despite recent evidence to the contrary--that beta-blocker therapy should be delayed until HF patients have been titrated to target doses of angiotensin-converting enzyme inhibitors and have been stable for at least 2 to 4 weeks after hospital discharge, and that early beta-blocker initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence substantiates that beta-blockers significantly reduce the risk of mortality and morbidity, including hospitalization for worsening HF, and have produced early survival benefits in patients with HF. It has also become evident that in-hospital initiation of life-prolonging cardiovascular therapies, including beta-blockers, has a positive impact on clinical outcomes and on long-term patient compliance. Overwhelming clinical evidence suggests that beta-blockers should be administered to all stable HF patients without contraindication and that this therapy should be initiated as soon as possible to ensure that patients derive early and long-term improvements in clinical outcomes.