Early Versus Delayed Beta-Blocker Initiation in Acute Decompensated Heart Failure: A Systematic Review of Clinical Outcomes and Safety

Abstract

Background: The optimal timing of beta-blocker initiation in acute decompensated heart failure (ADHF) remains controversial due to concerns regarding hemodynamic instability despite established long-term benefits.

Objective: To evaluate the clinical outcomes and safety of early versus delayed beta-blocker initiation in patients hospitalized with ADHF.

Methods: A systematic review was conducted across PubMed, Embase, Cochrane Library, and Scopus (2000–2025). Studies comparing early (during hospitalization after stabilization) versus delayed or no initiation of beta-blockers in ADHF were included. Outcomes assessed included mortality, rehospitalization, and adverse events. A total of 13 studies (3 randomized controlled trials and 10 observational studies) were included.

Results: Early beta-blocker initiation was consistently associated with reduced in-hospital and short-term mortality, along with lower rehospitalization rates. Patients initiated on therapy prior to discharge demonstrated improved adherence to guideline-directed medical therapy. Safety outcomes indicated that early initiation is well tolerated in hemodynamically stable patients, with only mild and manageable increases in hypotension and bradycardia. Delayed initiation or withdrawal was associated with worse outcomes, including increased mortality.

Conclusion: Early initiation of beta-blockers following hemodynamic stabilization in ADHF is associated with improved clinical outcomes and acceptable safety. These findings support in-hospital optimization of therapy, although further randomized trials are needed to refine timing strategies and patient selection.