Factors Influencing Internal Medicine Resident Beta-Blocker Discontinuation in Acute Decompensated Heart Failure

Heart failure is one of the leading causes of hospital admissions in North America. Although guidelines support the continuation of beta blockers on admission, hemodynamic considerations and mechanistic reasoning may prompt beta blocker discontinuation even in the absence of contraindications. Resident physicians often face this dilemma and are an important group in which to evaluate this decision-making.

Internal medicine residents at two institutions were presented with two scenarios: 1) whether to continue outpatient metoprolol succinate for a patient without evidence of shock admitted with acute decompensated heart failure (ADHF) and 2) beta blocker selection during a patient's index presentation with heart failure.

142 of 287 (49.5%) residents responded to the survey. In scenario 1, 61% of residents discontinued metoprolol succinate on admission. The top three concerns about continuing metoprolol were precipitating cardiogenic shock, discomfort with the vital signs range, and attending physician disagreement. In scenario 2, 74% of participants initiated metoprolol succinate, 25% chose carvedilol, and only 1 participant chose bisoprolol.

Drivers of inpatient beta blocker discontinuation should be considered by internal medicine training programs and heart failure guideline writers when opportunities arise to enact practice changes that align with evidence.