Beta blockers in right heart failure? Not yet.

An editorial in the current blue journal questions ‘dogma’ with regard to treatment of right ventricular heart failure, drawing attention to a study in that journal. Unfortunately for humans, it was a study in rats.

Nevertheless, these studies may be the first steps en-route to a paradigm shift.

Why is this important to me? All respiratory physicians see many patients with pulmonary hypertension. Mostly this is occurs in patients with significant lung disease, such as emphysema, as a ‘secondary’ phenomenon. More and more often, however, primary pulmonary hypertension is diagnosed – even amongst older patients.

 In patients with pulmonary hypertension, things really start to turn sour when the right side of the heart – which is responsible for pumping blood around the lungs – begins to fail. (The right ventricle of the heart is only a thin muscular structure, made to pump at low pressure, and cannot continually cope with high pressure in the pulmonary circulation). When the right heart fails, fluid builds up in the legs. When the right heart fails, inadequate blood supply to the left side of the heart and ultimately to the rest of the body ensues. When the right heart fails, the mortality clock starts to tick a little faster.


We do not have many treatments available for patients with right heart failure. You don’t have to be a rocket scientist (or even a cardiologist) to figure out that diuretic medication might be useful. Use of diuretic medication is always clinically effective when patients with right heart failure are carrying too much fluid. Come into hospital with right heart failure, and diuretic medication is pretty much the state of the art.

 In the last fifteen to twenty years there has been a revolution in the treatment of left heart failure. Sadly, with regard to right heart failure our best treatment, our ‘state of the art’, is lagging at least twenty years behind treatment of failure of the other side of the heart.

 With left heart failure, treatment that was previously thought to be unhelpful – the use of beta blockers, which slow the heart down – was ultimately proven, around 12 years ago, to be very helpful, and even to prolong life.


Trials in the recent blue journal, referred to in the editorial (and conducted in rats) investigated the use of carvedilol, a beta blocker, in rats who had been ‘given’ pulmonary hypertension and had developed right heart failure.


The rats that got the medication did significantly better.


We cannot, based on the results of this study, begin giving carvedilol to patients with right heart failure. However, this study – along with the trail blazed by beta blockers in left heart failure – should get us thinking about how we might construct clinical trials evaluating further the possibility of treating patients with right heart failure with beta blockers.