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Dec 05. Ver. 1 Beta-Blocker Tips in Heart Failure Adapted from The Cleveland Clinic Foundation Clinical Management of Heart Failure. Young J, Mills R. 2nd Ed. Professional Communications. 2004 New York Heart Association Classification NYHA Class I No physical activity limitation: ordinary physical exercise does not cause undue fatigue, chest pain, palpitations, or dyspnea NYHA Class II Slight limitation of physical activity: patient is comfortable at rest, but ordinary activity results in fatigue, chest pain, palpitations, or dyspnea NYHA Class III Marked limitation of physical activity: patient is comfortable at rest, but less than ordinary activity results in fatigue, chest pain, palpitations, or dyspnea NYHA Class IV Unable to carry out any physical activity without discomfort: symptoms of fatigue, chest pain, palpitations, or dyspnea are present even at rest, with increased discomfort with any physical activity Beta-Blockers: Issues to Consider Prescribe in every post-MI patient. Start when patient is not significantly congested. Wait to prescribe for NYHA IV patients until “dry”. Carvedilol and long-acting metolprolol are currently the only FDA-approved agents for HF and are the betablockers of choice. Based on the COMET trial, short-acting metoprolol was less effective than carvedilol. Long-acting metoprolol may be better tolerated in patients with reactive airway disease (β1– selective agent). Start with a low dose and titrate slowly to the target dose Carvedilol: Initiate at 3.125 mg twice daily and titrate to a target dose of 25 mg twice daily. Long-acting metoprolol: Initiate at 25 mg once daily and titrate to a target dose of 100 - 200 mg once daily. Short-term patient may deteriorate with more congestion, weakness, and fatigue, but long-term patients generally improve. If a patient does not tolerate one agent, try the other. Initiating Beta-Blockers in Heart Failure Patient selection: Mild-to-moderate heart failure (HF) Already receiving ACEI/ARB, diuretic, often digoxin and possibly an aldosterone antagonist Not recommended initially in patient hospitalized with decompensated HF or who has significant hypotention, pulmonary congestion, or problematic bradycardia (start drug after resolution of these difficulties even if patient is still hospitalized) Dosage: Carvedilol Start with 3.125 mg twice daily with meals for 2 weeks Counsel patient about side effects after initial dose and after each dose increase (take at bedtime) If the first dose is well-tolerated, double the dose after 1 to 4 weeks Continue to double the dose every 1 to 4 weeks until target dose is reached (slower up-titration may be required) - Target dose if weight less than or equal to 85 kg: 25 mg twice daily - Target dose if weight greater than 85 kg: 25 – 50 mg twice daily Instruct patients to take carvedilol with meals Long-acting metoprolol Start with 25 mg once daily (take at bedtime) If the first dose is well-tolerated, double the dose after 1 to 4 weeks Continue to double the dose every 1 to 4 weeks until target dose is reached (slower up-titration may be required) Target dose: 100 mg – 200 mg once daily Managing side effects during titration: Vasodilating effects (dizziness or light-headedness) Give carvedilol with food Give beta-blocker 2 hours before or after other vasoactive agents Give ACEI/ARB at bedtime and carvedilol or long-acting metoprolol in the morning (or reverse) Consider reducing doses of diuretics or other vasodilators temporarily Reduce beta-blocker dose only when other tactics fail May require no attention, as symptoms are often self-limiting Worsening HF (edema, weight gain, dyspnea): Intensify sodium restriction Increase diuretic dose Reduce beta-blocker dose only when other tactics fail Significant bradycardia (consistently less than 60 bpm with symptoms related to bradycardia): Reduce digoxin dose Reduce or eliminate amiodarone Assure that verapamil or diltiazem are discontinued Reduce beta-blocker dose only when other tactics fail Consider pacer (particularly biventricular device if QRS greater than 120 msec)
