Download actually taking β

Practical Tips in
β-blocker Therapy in CHF
CMCC 11th 11th September 2009
Rungsrit Kanjanavanit MD.
Cardiovascular Div. Dept. of Medicine
Faculty of Medicine , Chiang Mai Univ.
Circulation. 2009;119:1977-2016.
2551
βB
/ ARB
Utilization of HF medications in clinical practice
Euro Heart Survey
87
62
36
33
17
lac
to
ne
B
21
Sp
i ro
no
CC
Ni
tra
te
s
di
go
xi n
21
AC
EI
,B
B,
di
ur
et
ics
37
Be
ta
-b
lo
ck
er
s
Di
ur
et
ics
90
80
70
60
50
40
30
20
10
0
AC
EI
/A
RB
% 100
Komajda M et al. Eur Heart J 2003
Clinical trials VS Real world population
Trials excluded patients with relative
contraindications
 Not very old , mainly white men, no
complicated medical history


In real life , more than 75% have at least
one relative contraindication
Co-morbidities CMU HF clinic
70
60
50
44.4 % had > 3 comorbidities
40
62.2
30
60
20
20
10
51.1
33.3
15.6
11.1
0
CAD
DM
HT
dyslipid
CRF
COPD
Not adhering to guidelines

Can the difference between the real world
patients and RCT’s solely explain these
findings?
No
Euro Heart Survey on Heart Failure

83% of SOLVD-eligible were on ACEI

Almost half of these received the target dose as
recommended in the guidelines

54% of MERIT-HF-eligible were on β-blockers


10% of these received the target dose.
43%
of RALES-eligible
on
‘adherence’
related patients
solely towere
physicians
aldosterone following
antagonistguidelines,
not to patient compliance or persistence.
Lenzen MJ et al. European Heart Journal (2005) 26, 2706–2713
Barrier to β-blocker prescription


Uninformed clinicians
Perceived complexity in initiation and up-titration




Lack of time and expertise for “micromanagement”
required with complex regimen
Risk of intolerance and worsening of HF
symptoms with initiation
Perceived delay in beneficial effects on
outcomes
Economic restraints – in some hospital ,UC may
not cover evidenced-based β-blocker for HF
Drugs Prescriptions of Mr. Had-enough
1. Enalapril (20) ½ tab bid pc.
2. Bisoprolol (5) 1 tab OD.
3. Spironolactone (25) 1 tab OD.
6. Glibencarmide(5) 1½ tab bid ac
7. Metformin (500) 1 tab tid pc
POLYPHARMACY
4. Digoxin (0.25) ½ tab E.O.D.
5. Furosemide (40) 1 tab prn for
dyspnea ,edema or weight gain
> 1 kg in 2 days
8. Aspirin (300) 1 tab OD.
9. ISDN (10) 2 tab tid ac
10. Isordil (5) 1 tab SL prn
13. Warfarin (3) ½ tab o OD.
Except Mon. and Wed.
11. Amlodipine (10) 1 tab OD.
14. Warfarin (5) ½ tab o OD. Only
on Mon. and Wed.
12. Atrovastatin (20) 1 tab pc evening
15. Lorazepam 1 tab prn hs.
17. Omeprazole (20) 1 tab o OD
16. Senekot 2 tab o hs
Patients with Sys HF
Patients with Sys HF without contraindication to β-
Patients with Sys HF who are given β-blocker
( Doctor adherence to guideline)
Patients with Sys HF who are actually taking β-blocker
( Patients’ medical adherence )
Patients with Sys HF who are taking β-blocker at the target dose
We can do better !
β blocker in heart failure
Contra-indication
Strong indication
Tip # 1
Implementation of β blocker therapy -When?
A simplified criteria
1. Edema free
2. Not requiring intravenous
medication for HF
Which and what dose
Starting dose(mg)
Bisoprolol
1.25 od
Metroprolol CR/XL
12.5-25 od
Carvedilol
3.125 bid
Nebivolol
1.25 od
Target dose(mg)
10 od
200 od
25-50 bid
10 od
Titration period – weeks to months
Tip # 2 How to use β blocker

Start early but with low dose

Double dose at not less than 2 weekly interval

Aim for target dose or highest tolerated dose

Some β blocker is better than no β blocker

Monitor HR,BP,BW and signs of congestion

Check blood chemistry 1-2 week after inhibition
and 1-2 week after final dose titration
Fluid status
Perfusion
Dry
Wet
Warm
Dry and
Warm
Wet and
Warm
Cold
Dry and
Cold
Wet and
Cold
Tip # 3
Patient came in with decompensated HF
What to do

Wet and warm




IV diuretics
No need to decrease dose of β-blocker
Up-titrate dose of ACEi and β-blocker when stabilized
Wet and cold



Positive inotropic support (PDE inhibitors)
Decrease the dose of β-blocker by 50%
Reintroduction or up-titrate β-blocker when stabilized
B-CONVINCED
Beta-blocker CONtinuation Vs. INterrupion in
patients with Congestive heart failure hospitalizED
for a decompensation episode EHJ (2009) 30,1-7
HF improves
at Day 3
ADHF
β-blocker at
3 months
69
Keep
β-blocker
92.8 %
90 %
78
Stop
β-blocker
92.3 %
76 %
Plasma BNP, LOS, rehospitalization rate, death rate also similar
During ADHF, continuation of β-blocker is not associated
with delayed or lesser improvement, but with higher rate of
chronic prescription of β-blocker therapy after 3 months
Tip # 4 How to use Diuretics

Lower the dose or stop before initiation of
ACEi and spironolactone
(avoid hypovolemia )

Increase the dose before initiation of
β- blocker
( make sure there is no fluid retention )
The most important tool in HF management
• Weigh every morning
• After going to toilet
• Before getting dressed
• Before breakfast
Self daily weight monitoring :
If weight increases > 1 kg within 1 or 2 days
 double the dose of diuretics , until returns to ideal BW
Tip # 5 Dealing with low heart rate
If < 50 bpm, halve dose of β-blocker
 Review other medications


Drug interaction to look for :
Digitalis
 Verapamil / diltiazem - should be discontinue
 Amiodarone

Tips # 6
Be persistant ! Minor setback can be
overcome
 Any general sense of un-wellness will
generally resolve in a few week
 More than 85% will tolerate β blocker

Tip # 7
Problem solving : Hypotension

Asymptomatic low BP does not require any
change in therapy.

HypoPERFUSION not hypoTENSION is the
concern.

Dizziness,light-headedness and confusion

D/C nitrates, CCB , other vasodilators

reducing dose of the diuretics if no signs/symptoms of
congestion
Tip # 8
Always measure supine and upright BP in
every HF patients at every visit
Case
ผู้ป่วยชาย อายุ 21 ปี
ได้ รับการวินิจฉัยเป็ น DCM มาติดตามการรักษาหลังออกจากโรงพยาบาลอาการดีขึ ้น จาก
NYHA III เป็ น II
ตรวจร่างกาย : HR 100 bpm
BP 100/60 mmHg
No lung crepitation
No edema
ผลการตรวจห้ องปฏิบตั ิการ
serum Cr 1.3 mg/dl, K 4.0 mg/dl
การรักษาที่ได้ รับ
Ramipril 2.5mg/d
Furosemide 40mg/d
Digoxin 0.125mg/d
LV & RV Non-compaction
What would you do?
1.
Increase dose of ramipril (target dose 10mg/d)
2.
Add very low dose β-blocker
3.
Increase dose of digoxin (to control HR)
4.
Leave him with this regimen
(now asymptomatic)
ATLAS (Assessment of Treatment with
Lisinopril and Survival)
3164pt. NYHA II-IV, LV EF <30% F/U 45.7mo
Low (2.5-5.0mg)
Mortality (%)
44.9
CV mortality (%)
40.2
Hospitalization (no.)*
4327
HF hospitalization(no)*
1576
High (32.5-35mg)
42.5
37.2
3819
1999
ATLAS : low dose VS high dose NNT to avoid rehospitalization = 4
Circ.1999;100:2312-2318
LVESVI: Change From Baseline
Carvedilol &
Enalapril
Carvedilol
Enalapril
 LVESVI (ml/m2)
4
2
*
0
-2
**
**
**
M6
M12
M18
*
*
-4
-6
-8
-10
* P < 0.05, ** P < 0.001
M6
M12 M18
M6
M12
M18
CARMEN Study
LVEF: Change From Baseline
Carvedilol &
Enalapril
5
***
***
Enalapril
***
4
 LVEF (%)
Carvedilol
***
***
**
3
*
2
1
0
-1
M6
M12
M18
* P < 0.05; ** P < 0.01; *** P < 0.001
M6
M12 M18
M6
M12
M18
CARMEN Study
Comparing two different strategies
in patients receiving low dose ACEi
Increasing ACEi to
maximal doses
Adding β-blocker
Effect on symptoms
No change
Improved
Effect on risk of
death
8% reduction
30-40% reduction
Effect on risk of
death and
hospitalization
12% reduction
20-40% reduction
ATLAS
MERIT HF
Tip # 9
Combined use of low doses of
several drugs is preferred to a
large dose of a single agent.
Six patterns of taking medication among patients treated
for chronic illnesses who continue to take their medications
perfect adherence
1/6
1/6
1/6
some timing irregularity
1/6
1/6
1/6
miss an occasional single day’s dose
drug holidays three to four times a year
drug holiday monthly or more
take few or no doses
N Engl J Med 2005;353:487-97
Tip # 10
“ Good drugs do not work on patients
who do not take them ”
C. Everett Koop, M.D.
Inadequate education
poor self-motivation
Depression
forgetfulness
poor compliance
poor family
support
Excessive
cost
drugs side effect
Complexity of the medication regimen
Pyramid of HF care
Heart transplant
Revascularization
Resynchronization Therapy
Pharmacologic Therapy
Patient education
Disease management program
Self management
Low tech – high touch therapy
“ filling the G A P in the care of chronic diseases ”
10 Practical Tips - Summary
1.
2.
3.
4.
A simplified criteria when to start
How to titrate and what to monitor
Do not stop blocker when patients come
in with ADHF unless inotropes is needed
(low output syndrome)
Know how to use diuretics effectively
1.
2.
Flexible regimen
Dealing with diuretic resistance
10 Practical Tips - Summary
5.
Dealing with low heart rate
6.
Be persistent
7.
Hypotension VS hypoperfusion
8.
Measure both supine and upright BP in every
HF patients at every visit
9.
Combined use of low to moderate doses of
several drugs is preferred to a large dose of a
single agent
10.
Nurses are doctor’s best friend
Thank you