Switching Between Beta Blockers in Heart Failure Patients: Rationale and Practical Considerations

Abstract

The clinical benefit of β blockade has been proven in a variety of pathologic settings, including hypertension, angina pectoris, acute‐ and post‐myocardial infarction, and congestive heart failure. However, β blockers do not all share the same clinical outcomes with respect to efficacy or safety in many of these conditions. This is especially true in HF, where differences in reverse remodeling and effects on the periphery may be important differentiating factors leading to improved efficacy. In fact, β blockers are a heterogeneous group of agents with respect to pharmacology, receptor biology, hemodynamic effects, and tolerability. As cardiovascular disease progresses, the issue of switching from one β blocker to another is an important consideration as to how to optimize the effectiveness of adrenergic blockade. Because of the differences among β blockers, switching should be conducted in a manner that takes into account pharmacologic differences. For example, the similarities and differences of receptor subtype blockade of the two agents and the potential effects of ancillary properties. Two protocols for switching between carvedilol, a third‐generation nonselective agent with vasodilation through α₁ blockade, and a β₁‐selective agent (e.g., metoprolol, atenolol) are described to simplify the process and maximize the safety and tolerability of this procedure. The optimal selection and use of adrenergic‐blocking agents in the cardiovascular continuum will assist in providing improved management while minimizing safety and tolerability concerns.