Congestive Heart Failure

ICD Referral Guidelines

How to Use a Beta Blocker

The addition of beta-blocker therapy to standard triple therapy for HF (digoxin, diuretic and ACE inhibitor) such as in the U.S. Carvedilol Trials1 (LVEF £ 35%; carvedilol 12.5-100mg/day) have shown a further 65% RRR in CV mortality (7.8% to 3.2 % ARR) in patients with NYHA class II-IV symptomatic HF. Carvedilol has also been shown to produce a dose related increase in LVEF which averaged 8% and to lead to a 27% relative risk reduction in cardiovascular hospitalizations. Similar benefits were obtained in other trials of beta-blockers in Heart Failure (MERIT2 -metoprolol and CIBIS II3 - bisoprolol). The Copernicus trial has extended the benefit of b-blockade to Class IV HF patients4.

Despite this many physicians are reluctant to utilize beta-blockers in heart failure for fear of provoking clinical deterioration. Physicians should bear in mind that they already have many patients in their practice with silent or asymptomatic LV dysfunction who are tolerating beta-blockers very well (post MI patients). Judicious initiation of beta blockade will not provoke sudden severe heart failure. Most patients tolerate the addition of a beta-blocker very well. The key is to START LOW AND GO SLOW utilizing the beta-blocker medications and doses used in the clinical trials.

In addition the close monitoring required is a clinical deterrent to beta-blocker usage. In many instances patients can be initiated on beta-blockers and up-titrated with less frequent clinical visits. In this case a START LOWER AND GO SLOWER strategy is advised and is particularly useful in a busy primary care setting. Patients can up-titrate themselves and backtrack if symptoms develop. It is recommended to start with the START LOWER AND GO SLOWER beta-blocker protocol until you are familiar and comfortable with beta-blocker therapy.

The accompanying beta-blocker titration protocols are recommended as advice and do not replace clinical judgment or appropriate consultation. Beta-blockers should be initiated in the stable HF patient, free of clinical congestion. ACE inhibition should be optimized prior or simultaneous with beta-blocker titration. Dietary, lifestyle and exercise interventions should be carried out concurrently. All cardiac risk factors should be modified aggressively. Treatable causes of HF should be identified. Reversible triggers of HF should be dealt with.

See Beta-blocker titration protocols for both the standard START LOW AND GO SLOW

See the Guide for Heart Failure (HF) Management for further guidance in this regard.

1. NEJM 1996; 334:1349-1355.
2. Lancet 1999; 353: 2001-2007.
3. Lancet 1999; 353: 9-13
4. Presented ESC meeting-Amsterdam; Aug 2000

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