The prognostic impact of beta blockers in ischemic heart failure: time for a paradigm shift?

Beta-blockers are traditionally considered a cornerstone of the pharmacological therapy in heart failure (HF) post-myocardial infarction (MI) and their use in this setting recognizes a pathophysiological rationale. However, most of evidence supporting their administration in ischemic HF is dated and was conceived before the introduction of modern reperfusion therapies (the so-called “pre-reperfusion era”). The introduction of cutting-edge techniques for revascularization and pharmacological strategies changed the history of MI, reducing mortality and allowing to many patients to overcome the acute event without residual ventricular dysfunction. In the “reperfusion era”, the impact of beta-blocker therapy is different than previously observed and evidence coming from new studies lead to question their role as inevitable drugs after acute events, principally in patients with preserved left ventricular ejection fraction. Consequently, the clinical need of prescribing beta-blockers across the full spectrum of ischemic HF patients has become a debated question. This review aims to retrace the history of beta-blockers in ischemic HF, focusing on recent and ongoing trials, that will offer new and update evidence to guide clinical practice in the next future. Since a “one-size-fits-all” approach cannot be justified, our aim is to propose a tailored approach to each patient’s profile, based on left ventricular ejection fraction, comorbidities, arrhythmic burden and quality of life. Furthermore, we propose an algorithm to guide the therapeutic decision of begin, withhold or withdrawn therapy with beta-blockers from the MI onset to the chronical phase of ischemic HF.