Key points to remember
- Beta-blockers are a proven class of drugs prescribed to patients who have suffered a heart attack or are suffering from heart failure.
- New research shows that long-term use of beta-blockers may not improve outcomes in some patients, especially those with only mildly reduced heart function.
- People who have had a heart attack should take their medications as prescribed and see their cardiologist regularly to assess their treatment plan.
Beta-blockers have been a long-standing treatment for patients after a heart attack because they protect the heart from further damage. They also support heart function in people with heart dysfunction or heart failure. But three new studies published in quick succession show that long-term use of beta-blockers may not be as beneficial for some patients as previously thought.
Although researchers have identified some pitfalls of long-term use of beta-blockers, experts say these drugs will still be prescribed and helpful to many patients. But there are also several other heart disease treatments that they want people to know about.
What are beta-blockers and why are they prescribed?
If you’ve ever ridden a roller coaster or been spooked by someone sneaking up behind you, you’ve probably felt the effects of adrenaline, the body’s “fight or flight” hormone. Adrenaline, also known as epinephrine, is a catecholamine, a class of hormones that the nervous system makes in response to stress.
Adrenaline speeds up heart rate and breathing. It also causes the arteries to constrict or narrow, which raises your blood pressure. The body releases a surge of adrenaline during times of stress, but continuously produces small amounts to keep your blood pressure and heart rate within optimal limits.
Beta-blockers block receptor sites for catecholamines, especially adrenaline, in the heart and arteries. When beta-blockers prevent adrenaline from doing its job, the heart rate slows and the arteries cannot constrict, which lowers blood pressure.
This effect is important after a heart attack, when the heart muscle surrounding the blockage is weakened. The purpose of a beta-blocker is to prevent the heart muscle from remodeling or becoming stiff and fibrous after a heart attack. A stiff heart muscle cannot pump as efficiently, which can lead to permanent heart failure.
However, research suggests that beta-blockers don’t always achieve this goal.
Recent studies evaluate the use of beta-blockers
Three recent studies have assessed the merits of using beta-blockers in patients with heart attack or heart failure. Everyone has concluded that beta-blockers are not for everyone.
Beta-blockers after a heart attack
Two of the studies looked specifically at heart attack patients.
The first study followed 43,618 patients in Sweden who were prescribed beta-blockers after a heart attack between 2005 and 2016. The researchers concluded that using beta-blockers beyond one year did not improve not cardiovascular outcomes in patients who had not developed heart failure after their heart attack. .
The second study looked at data from 262,972 patients who had their first heart attack between 2018 and 2023. Of these patients, 80% had been prescribed beta-blockers after their heart attack. Across all patient demographics, researchers found that patients who received beta-blockers were 16.5% more likely to have a second heart attack within the first year.
Beta blockers for heart failure
The third study evaluated patients with heart failure instead of heart attack survivors and measured what is called ejection fraction.
Ejection fraction (EF) can be an important measure of heart failure that can be measured with an echocardiogram or cardiac ultrasound. It refers to the percentage of blood pumped out of the lower chambers of the heart with each beat. The lower the EF, the less efficiently the heart pumps, which leads to a lack of adequate blood circulation in the body.
- An EF of 50-70% is considered “normal”. Your heart can circulate enough blood to meet your body’s needs.
- An EF of 41 to 49% is “borderline”. With a slightly lower EF, you may notice some symptoms like stuffiness during activity.
- An EF of 40% or less is greatly reduced. Normal daily activities may become difficult to perform without fatigue, and you may be short of breath at rest.
A low EF can indicate heart failure, but it is not present in all patients with heart failure.
The researchers evaluated 435,897 patients aged 65 and older with heart failure on beta-blockers. All patients had an EF of 40% and above, so none of the patients had severely reduced cardiac function. The researchers found that for patients whose EF was between 40% and 60%, the benefits of beta-blockers actually decreased as the EF increased.
The researchers also concluded that there was no survival benefit to beta-blockers in patients with an EF greater than 60%. In fact, a patient’s risk of developing heart failure or being hospitalized and dying was actually bigger if they continued to take beta-blockers as EF increased.
What does this mean for the future of heart disease care?
Much of the long-term damage from a heart attack results from a lack of blood flow to the heart, and beta-blockers aren’t the only way to get that back on track.
“We have such good strategies for quickly restoring blood flow to the heart that many of the historical benefits of beta-blockers are negated,” Andy Lee, MD, cardiologist at UCI Health in Irvine, Calif., told Verywell.
Stents, cholesterol-lowering drugs, and cardiac rehabilitation are other treatment options that reduce the risk of recurrent heart disease after a heart attack.
The decision to continue beta-blockers can be nuanced and requires discussion between patient and provider.
“Beta-blockers are great medications for patients who have had a heart attack before, but long-standing beta-blocker therapy isn’t always indicated,” Lee said. “Someone who is physically active may be more sensitive to taking a beta-blocker. However, if they are experiencing chest pain or have a low EF, a beta-blocker may be more beneficial.
When it comes to heart failure, beta-blockers still play a vital role in improving long-term outcomes for some patients, especially those with low EF.
“For people with heart failure with weakened heart muscle, beta-blockers remain the standard of care unless they have contraindications,” said Deepak L. Bhatt, MD, MPH, director of Mount Sinai Heart in New York, to Verywell, adding that patients with atrial fibrillation are also candidates for beta-blocker therapy.
Beta-blockers are just one class of drugs used to treat heart failure. Four classes of drugs, known as the “four pillars” of heart failure treatment, are recommended for the management of heart failure. In addition to beta-blockers, a cardiologist may recommend:
- ACE inhibitors, ARBs or ARNI: These drugs reduce blood pressure and prevent the remodeling of heart muscle.
- Mineralocorticoid receptor antagonists (MRAs): They are mild diuretics. They alleviate excessive fluid accumulation in heart failure. The most common example is the drug spironolactone.
- Sodium-glucose co-transporter 2 inhibitors: This is a relatively new class of drugs originally designed to treat type 2 diabetes. Recent evidence shows that they can improve heart function in patients with heart failure with ejection fraction reduced (HFrEF) independent of diabetic status. Farxiga and Jardiance are the most popular drugs in this class for heart failure.
“The professional guidelines continue to be updated. Many of these drugs are underused and we want to encourage providers to prescribe them unless they are contraindicated,” Bhatt said. “The goal is to get all four drug classes on board, even at lower doses.”
What this means for you
Beta-blockers remain important medications for patients whose heart is not functioning optimally. Do not stop any medicine without first talking to your doctor. If you’ve had a heart attack or have heart failure, see your cardiologist regularly to discuss your medications and treatment plan.