Pathophysiology of the beta-adrenoceptor system in chronic heart failure: consequences for treatment with agonists, partial agonists or antagonists?

The human heart contains both beta 1-adrenoceptors and a considerable number of beta 2-adrenoceptors, both of which bring about positive inotropic and chronotropic effects of beta-adrenoceptor agonists in vitro and in vivo. In chronic heart failure, the decrease in beta-adrenoceptor function is related to the severity of the disease. However, both cardiac beta 1- and beta 2-adrenoceptors seem to be differentially affected depending on the type of heart failure and its aetiology. beta 1-adrenoceptor function decreases in all forms of chronic heart failure. beta 2-adrenoceptor function, on the other hand, decreases in mitral valve disease, tetralogy of Fallot and end-stage ischaemic cardiomyopathy, and seems to be unaltered (or only mildly uncoupled) in end-stage dilated cardiomyopathy, and possibly in aortic valve disease. Since the human heart has few spare beta-adrenoceptors and these decline with increasing degree of heart failure, beta-adrenoceptor agonists (but only non-selective full agonists) may be of therapeutic use only if the heart needs acute inotropic support; in long-term treatment they may be not effective, since tolerance develops. On the other hand, for long-term treatment selective beta 1-adrenoceptor antagonists may be beneficial since they protect the heart from the deleterious effects of chronic exposure to high (cardiac derived) noradrenaline and simultaneously may restore the previously reduced beta-adrenoceptor function.