Beta-blockers in acute decompensated heart failure with and without cardiogenic shock: Should we initiate, continue, or withdraw? A systematic review and meta-analysis.

OBJECTIVE: to evaluate the impact of beta-blocker (BB) initiation, continuation, and withdrawal on in-hospital mortality in patients with severe acute decompensated heart failure (ADHF), particularly those presenting with cardiogenic shock (CS). DESIGN: systematic review and meta-analysis. SETTING: cohort studies and randomized controlled trials (RCTs) published through December 31, 2024. PATIENTS OR PARTICIPANTS: adult patients with ADHF and CS. INTERVENTIONS: parenteral beta-blocker. MAIN VARIABLES OF INTEREST: in-hospital mortality. RESULTS: Sixteen studies (12 cohorts and 4 RCTs) comprising 23,947 patients were included. Among them, 3,215 presented with CS, and 1,246 died. Of the total population, 12,952 received BBs and 10,549 did not. Initiation of BBs in previously untreated patients with CS was not associated with a reduction in mortality (RR: 0.82; 95% CI: 0.64–1.04). Continuation of BBs in patients already receiving them at admission significantly reduced mortality by 49% (RR: 0.51; 95% CI: 0.43–0.61). In contrast, BB withdrawal was not associated with increased mortality risk (RR: 1.92; 95% CI: 0.37–10.09). CONCLUSIONS: In adult patients with ADHF and CS, continuing BB therapy appears to improve survival, while discontinuation may be harmful. Initiation of BBs in previously untreated patients might also offer benefits, although the evidence is inconclusive. These findings highlight the importance of individualized BB strategies in critically ill HF patients, though they should be interpreted with caution due to study heterogeneity.