-Blockers in Chronic Heart Failure

Case 1: A 54-year-old man with a history of myocardial infarction (MI) presented with exertional dyspnea. Physical examination was unremarkable. Left ventricular ejection fraction (LVEF) by Doppler echocardiography was 35%, and a stress test was negative for ischemia. The patient was taking aspirin, a statin, and an angiotensin converting enzyme (ACE) inhibitor. He was started on 12.5 mg/d metoprolol controlled-release/extended release (CR/XL) and titrated to a target dose of 200 mg/d over several weeks. Case 2: A 65-year-old woman with a history of heart failure (HF) due to hypertension (HTN) continued to have dyspnea with exertion and occasionally at rest. On physical examination, there was no jugular venous distention or ankle edema. Her LVEF was 10%. She was taking a loop diuretic, digoxin, and an ACE inhibitor; 3.125 mg twice/d carvedilol was added and slowly titrated to a target dose of 25 mg twice/d. Chronic HF is a common clinical syndrome resulting from coronary artery disease (CAD), HTN, valvular heart disease, and/or primary cardiomyopathy.1,2 There is now conclusive evidence that -blockers, when added to ACE inhibitors, substantially reduce mortality, decrease sudden death, and improve symptoms in patients with HF. Despite the overwhelming evidence3–6 and guidelines1,7,8 that mandate the use of -blockers in all HF patients without contraindications, many patients do not receive this treatment.9