[Treatment with beta blockers in advanced heart failure]

Sympathetic activation plays an important role in the progression of heart failure, and beta-blocker treatment not only improves ventricular function but may also slow and reverse heart remodeling. Patients with severe heart failure remain markedly symptomatic and have a poor prognosis despite optimal pharmacological treatment which includes an ACE-inhibitor. In these patients the tolerability of beta-blockers is reduced, but they could have the most to gain from this therapy, since they are more likely to show symptomatic and survival improvement in the long term. With close clinical observation during the initiation and titration of the drug, and an adequate adjustment of associated therapy, beta-blockers are tolerated in the majority of such patients. This article reviews the clinical experience of beta-blocker use in advanced heart failure, and discusses the appropriate modality of drug initiation and titration. Considerations are also made about the usefulness of prognostic parameters in the evaluation of tolerability and efficacy of beta-blocker treatment.