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An Updated Review on the Role of Non-dihydropyridine Calcium Channel Blockers and Beta-blockers in Atrial Fibrillation and Acute Decompensated Heart Failure: Evidence and Gaps

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Abstract

Purpose

The 2021 European Society of Cardiology guidelines on acute and chronic heart failure (HF) recommend that non-dihydropyridine calcium channel blockers (NDCC) should be avoided in patients with HF with reduced ejection fraction. It also emphasizes that beta-blockers only be initiated in clinically stable, euvolemic patients. Despite these recommendations, NDCC and beta-blockers are often still employed in patients with AF with rapid ventricular response and acute decompensated HF. The relative safety and efficacy of these therapies in this setting is unclear.

Methods

To address the question of the safety and efficacy of NDCC and beta-blockers for acute rate control in decompensated HF, we provide a perspective on the literature of NDCC and beta-blockers in chronic HF with reduced and preserved ejection fraction and AF, including trials on the management of AF with rapid ventricular response with and without HF.

Results

Robust data demonstrates mortality benefits when beta-blockers are used in patients with chronic HF with reduced ejection fraction. The data that inform the contraindication of NDCC in HF with reduced ejection fraction are outdated and were not primarily designed to address the efficacy and safety of rate control of AF in patients with HF. Several studies indicate that for acute rate control, NDCC and beta-blockers are both efficacious therapies, especially in the setting of tachycardia-induced cardiomyopathy.

Conclusion

Future studies are needed to assess the safety and efficacy of beta-blockers and NDCC in both acute and chronic AF with HF with reduced and preserved ejection fraction.

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Funding

The study was funded by the John S. Dunn Chair in Cardiology Research and Education. This work was also supported by a Grant from the Comunidad Autónoma de Madrid (B2017/BMD-3738).

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Authors and Affiliations

  1. Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Jeffrey Triska

  2. Department of Pharmacology and Toxicology School of Medicine, Institute Gregorio Marañón, Universidad Complutense, Madrid, Spain

    Juan Tamargo

  3. Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA

    Biykem Bozkurt & Yochai Birnbaum

  4. Department of Medicine, Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Uri Elkayam

  5. Department of Medicine, Division of Hypertension and Clinical Pharmacology, Baylor College of Medicine, Houston, TX, USA

    Addison Taylor

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  1. Jeffrey Triska
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  2. Juan Tamargo
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  4. Uri Elkayam
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Contributions

The concept for the manuscript was provided by Yochai Birnbaum. The original manuscript was written by Jeff Triska with significant edits by all other authors. All authors approved the final manuscript.

Corresponding author

Correspondence to Jeffrey Triska.

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Conflict of interest

Jeffrey Triska—None.

Juan Tamargo—None.

Biykem Bozkurt—In regard to beta-blockers, consulting fees from Bristol Myers Squibb, scPharmaceuticals Inc., Baxter Healthcare Corporation, Sanofi-Aventis, Relypsa, Amgen and serves on the Clinical Event Committee for Haemodynamic-guided management of heart failure (GUIDE-HF) trial sponsored by Abbott Vascular, and Data Safety Monitoring Committee of Autonomic REGULATION Therapy to Enhance Myocardial Function and Reduce progression of Heart Failure with reduced ejection fraction (ANTHEM) sponsored by Liva Nova.

Uri Elkayam—None.

Addison Taylor—None.

Yochai Birnbaum—Research grant from AstraZeneca for ticagrelor and dapagliflozin.

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Triska, J., Tamargo, J., Bozkurt, B. et al. An Updated Review on the Role of Non-dihydropyridine Calcium Channel Blockers and Beta-blockers in Atrial Fibrillation and Acute Decompensated Heart Failure: Evidence and Gaps. Cardiovasc Drugs Ther 37, 1205–1223 (2023). https://doi.org/10.1007/s10557-022-07334-y

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