Congestive heart failure beta blockers: Difference between revisions

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{{CMG}}
{{CMG}}


'''Editor(s)-In-Chief:''' James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [mailto:jchang@caregroup.org] and [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School; {{AOEIC}} {{LG}} {{Mitra}}
'''Editor(s)-In-Chief:''' James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [mailto:jchang@caregroup.org] and [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School; {{AOEIC}} {{LG}} {{Mitra}} {{EdzelCo}}


==Beta Blockers==
==[[Beta Blockers]]==
===Indications for Beta Blockers Use===
===[[Indications]] for [[Beta Blockers]] Use===
A patient should be administered a "heart failure approved" or "evidence-based " beta blocker ([[metoprolol succinate]]<ref name="pmid10714728">{{cite journal |author=Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P |title=Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group |journal=[[JAMA : the Journal of the American Medical Association]] |volume=283 |issue=10 |pages=1295–302 |year=2000 |month=March |pmid=10714728 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10714728 |accessdate=2012-04-03}}</ref>, [[carvedilol]], [[bisoprilol|bisoprolol]]) if:
A [[patient]] should be administered a "[[heart failure]] approved" or "evidence-based " [[beta blocker]] ([[metoprolol succinate]]<ref name="pmid10714728">{{cite journal |author=Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P |title=Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group |journal=[[JAMA : the Journal of the American Medical Association]] |volume=283 |issue=10 |pages=1295–302 |year=2000 |month=March |pmid=10714728 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10714728 |accessdate=2012-04-03}}</ref>, [[carvedilol]], [[bisoprilol|bisoprolol]]) if:


1. The [[Left Ventricular Ejection Fraction]] ([[LVEF]]) is ≤ 40%
1. The [[Left Ventricular Ejection Fraction]] ([[LVEF]]) is ≤ 40%
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===Background===
===Background===
* Blockade of compensatory sympathetic stimulation is associated with arrhythmic, ischemic, remodeling, and apoptotic benefits.
* [[Blockade]] of compensatory [[sympathetic]] stimulation is associated with [[arrhythmic]], [[ischemic]], [[remodeling]], and [[apoptotic]] benefits.
* Used as monotherapy or combined with conventional [[heart failure]] management, [[beta blockers]] reduce the combined risk of morbidity and mortality.
* Used as [[monotherapy]] or combined with conventional [[heart failure]] [[management]], [[beta blockers]] reduce the combined risk of [[morbidity]] and [[mortality]].
*[[Beta blocker]] therapy is recommended for ANY patient with reduced [[left ventricular ejection fraction]] (≤ 40%) regardless of the etiology of [[left ventricular systolic dysfunction]] (ischemic or nonischemic) or presence/absence of symptoms. Patients with or without [[heart failure]] (in other words, even those with asymptomatic [[left ventricular systolic dysfunction]]) are included in this recommendation.
*[[Beta blocker]] therapy is recommended for ANY [[patient]] with reduced [[left ventricular ejection fraction]] (≤ 40%) regardless of the [[etiology]] of [[left ventricular systolic dysfunction]] ([[ischemic]] or [[nonischemic]]) or presence/absence of [[symptoms]]. [[Patients]] with or without [[heart failure]] (in other words, even those with [[asymptomatic]] [[left ventricular systolic dysfunction]]) are included in this recommendation.
*[[Beta blockers]] approved by the FDA for use in the treatment of [[heart failure]] are [[metoprolol succinate]] and [[carvedilol]]. In Europe, [[bisoprolol]] is also approved for use in [[heart failure]]. In addition, [[beta blocker]] therapy is indicated for patients with history of [[myocardial infarction]] whether or not [[left ventricular systolic dysfunction]] or [[heart failure]] is present.
*[[Beta blockers]] approved by the FDA for use in the [[treatment]] of [[heart failure]] are [[metoprolol succinate]] and [[carvedilol]]. In Europe, [[bisoprolol]] is also approved for use in [[heart failure]]. In addition, [[beta blocker]] [[therapy]] is indicated for [[patients]] with history of [[myocardial infarction]] whether or not [[left ventricular systolic dysfunction]] or [[heart failure]] is present.
*[[Beta blocker]] therapy should be initiated at low dosage and gradually uptitrated, as tolerated, toward target dosages of 200 mg daily for [[metoprolol succinate]] and 25 mg twice daily for [[carvedilol]], or to the maximum tolerated dosage.
*[[Beta blocker]] [[therapy]] should be initiated at low [[dosage]] and gradually uptitrated, as tolerated, toward target [[dosages]] of 200 mg daily for [[metoprolol succinate]] and 25 mg twice daily for [[carvedilol]], or to the maximum tolerated dosage.
* Other beta-blockers (such as atenolol) have not been demonstrated to have the same mortality benefits as carvedilol and metoprolol and should not be used for this purpose.
* Other [[beta-blockers]] (such as [[atenolol]]) have not been demonstrated to have the same [[mortality]] benefits as [[carvedilol]] and [[metoprolol]] and should not be used for this purpose.






===Dosing===
===[[Dosing]]===
{| class="wikitable
{| class="wikitable
!Beta Blocker !! Starting dose!! Target dose
![[Beta Blocker]] !! Starting [[dose]]!! [[Target dose]]
|-
|-
| Bisoprolol||align="center"|1.25 mg QD||align="center"|10 mg QD
| [[Bisoprolol]]||align="center"|1.25 mg [[QD]]||align="center"|10 mg [[QD]]
|-
|-
| Carvedilol||align="center"|3.125 mg BID||align="center"|50 mg BID
| [[Carvedilol]]||align="center"|3.125 mg [[BID]]||align="center"|50 mg [[BID]]
|-
|-
| Carvedilol CR||align="center"|10 mg QD||align="center"|80 mg QD
| [[Carvedilol CR]]||align="center"|10 mg [[QD]]||align="center"|80 mg [[QD]]
|-
|-
| Metoprolol succinate (CR/XL)||align="center"|12.5–25 mg QD||align="center"| 200 mg QD
| [[Metoprolol succinate]] (CR/XL)||align="center"|12.5–25 mg QD||align="center"| 200 mg [[QD]]
|-
|-
| Nebivolol||align="center"|1.25 mg QD||align="center"| 10 mg QD
| [[Nebivolol]]||align="center"|1.25 mg [[QD]]||align="center"| 10 mg [[QD]]
|}
|}


==2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT) <ref name="Hunt">Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>==
== 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500  }} </ref>==


===Blockers in Patients Presenting With Heart Failure (DO NOT EDIT) <ref name="Hunt">Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>===


{| class="wikitable" style="width:80%"
====Beta Blockers====
 
{|class="wikitable" style="width:80%"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


|-
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' [[Beta blockers]] (using 1 of the 3 proven to reduce mortality, i.e., [[bisoprolol]], [[carvedilol]], and [[metoprolol|sustained release metoprolol succinate]]) are recommended for all stable patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]), unless contraindicated.<ref name="pmid10023943">{{cite journal |author= |title=The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial |journal=[[Lancet]] |volume=353 |issue=9146 |pages=9–13 |year=1999 |month=January |pmid=10023943 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673698111819 |accessdate=2012-04-05}}</ref><ref name="pmid10714728">{{cite journal |author=Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P |title=Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group |journal=[[JAMA : the Journal of the American Medical Association]] |volume=283 |issue=10 |pages=1295–302 |year=2000 |month=March |pmid=10714728 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10714728 |accessdate=2012-04-05}}</ref><ref name="pmid11386264">{{cite journal |author= |title=A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure |journal=[[The New England Journal of Medicine]] |volume=344 |issue=22 |pages=1659–67 |year=2001 |month=May |pmid=11386264 |doi=10.1056/NEJM200105313442202 |url=http://dx.doi.org/10.1056/NEJM200105313442202 |accessdate=2012-04-05}}</ref><ref name="pmid12853193">{{cite journal |author=Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, Lubsen J, Lutiger B, Metra M, Remme WJ, Torp-Pedersen C, Scherhag A, Skene A |title=Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial |journal=[[Lancet]] |volume=362 |issue=9377 |pages=7–13 |year=2003 |month=July |pmid=12853193 |doi=10.1016/S0140-6736(03)13800-7 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(03)13800-7 |accessdate=2012-04-05}}</ref><ref name="pmid10376614">{{cite journal |author= |title=Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) |journal=[[Lancet]] |volume=353 |issue=9169 |pages=2001–7 |year=1999 |month=June |pmid=10376614 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673699044402 |accessdate=2012-04-05}}</ref><ref name="pmid9743509">{{cite journal |author=Lechat P, Packer M, Chalon S, Cucherat M, Arab T, Boissel JP |title=Clinical effects of beta-adrenergic blockade in chronic heart failure: a meta-analysis of double-blind, placebo-controlled, randomized trials |journal=[[Circulation]] |volume=98 |issue=12 |pages=1184–91 |year=1998 |month=September |pmid=9743509 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=9743509 |accessdate=2012-04-05}}</ref><ref name="pmid8614419">{{cite journal |author=Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH |title=The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group |journal=[[The New England Journal of Medicine]] |volume=334 |issue=21 |pages=1349–55 |year=1996 |month=May |pmid=8614419 |doi=10.1056/NEJM199605233342101 |url=http://dx.doi.org/10.1056/NEJM199605233342101 |accessdate=2012-04-05}}</ref><ref name="pmid11386263">{{cite journal |author=Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne A, Roecker EB, Schultz MK, DeMets DL |title=Effect of carvedilol on survival in severe chronic heart failure |journal=[[The New England Journal of Medicine]] |volume=344 |issue=22 |pages=1651–8 |year=2001 |month=May |pmid=11386263 |doi=10.1056/NEJM200105313442201 |url=http://dx.doi.org/10.1056/NEJM200105313442201 |accessdate=2012-04-05}}</ref><ref name="pmid11356434">{{cite journal |author=Dargie HJ |title=Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial |journal=[[Lancet]] |volume=357 |issue=9266 |pages=1385–90 |year=2001 |month=May |pmid=11356434 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673600045608 |accessdate=2012-04-05}}</ref><ref name="pmid12853194">{{cite journal |author=Cleland JG, Pennell DJ, Ray SG, Coats AJ, Macfarlane PW, Murray GD, Mule JD, Vered Z, Lahiri A |title=Myocardial viability as a determinant of the ejection fraction response to carvedilol in patients with heart failure (CHRISTMAS trial): randomised controlled trial |journal=[[Lancet]] |volume=362 |issue=9377 |pages=14–21 |year=2003 |month=July |pmid=12853194 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673603138019 |accessdate=2012-04-05}}</ref><ref name="pmid8106700">{{cite journal |author=Fisher ML, Gottlieb SS, Plotnick GD, Greenberg NL, Patten RD, Bennett SK, Hamilton BP |title=Beneficial effects of metoprolol in heart failure associated with coronary artery disease: a randomized trial |journal=[[Journal of the American College of Cardiology]] |volume=23 |issue=4 |pages=943–50 |year=1994 |month=March |pmid=8106700 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0735-1097(94)90641-6 |accessdate=2012-04-05}}</ref><ref name="pmid7963115">{{cite journal |author=Metra M, Nardi M, Giubbini R, Dei Cas L |title=Effects of short- and long-term carvedilol administration on rest and exercise hemodynamic variables, exercise capacity and clinical conditions in patients with idiopathic dilated cardiomyopathy |journal=[[Journal of the American College of Cardiology]] |volume=24 |issue=7 |pages=1678–87 |year=1994 |month=December |pmid=7963115 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid7722114">{{cite journal |author=Olsen SL, Gilbert EM, Renlund DG, Taylor DO, Yanowitz FD, Bristow MR |title=Carvedilol improves left ventricular function and symptoms in chronic heart failure: a double-blind randomized study |journal=[[Journal of the American College of Cardiology]] |volume=25 |issue=6 |pages=1225–31 |year=1995 |month=May |pmid=7722114 |doi=10.1016/0735-1097(95)00012-S |url=http://linkinghub.elsevier.com/retrieve/pii/0735-1097(95)00012-S |accessdate=2012-04-05}}</ref><ref name="pmid7664433">{{cite journal |author=Krum H, Sackner-Bernstein JD, Goldsmith RL, Kukin ML, Schwartz B, Penn J, Medina N, Yushak M, Horn E, Katz SD |title=Double-blind, placebo-controlled study of the long-term efficacy of carvedilol in patients with severe chronic heart failure |journal=[[Circulation]] |volume=92 |issue=6 |pages=1499–506 |year=1995 |month=September |pmid=7664433 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7664433 |accessdate=2012-04-05}}</ref><ref name="pmid7902479">{{cite journal |author=Waagstein F, Bristow MR, Swedberg K, Camerini F, Fowler MB, Silver MA, Gilbert EM, Johnson MR, Goss FG, Hjalmarson A |title=Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Metoprolol in Dilated Cardiomyopathy (MDC) Trial Study Group |journal=[[Lancet]] |volume=342 |issue=8885 |pages=1441–6 |year=1993 |month=December |pmid=7902479 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid7923660">{{cite journal |author= |title=A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). CIBIS Investigators and Committees |journal=[[Circulation]] |volume=90 |issue=4 |pages=1765–73 |year=1994 |month=October |pmid=7923660 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7923660 |accessdate=2012-04-05}}</ref><ref name="pmid8941104">{{cite journal |author=Packer M, Colucci WS, Sackner-Bernstein JD, Liang CS, Goldscher DA, Freeman I, Kukin ML, Kinhal V, Udelson JE, Klapholz M, Gottlieb SS, Pearle D, Cody RJ, Gregory JJ, Kantrowitz NE, LeJemtel TH, Young ST, Lukas MA, Shusterman NH |title=Double-blind, placebo-controlled study of the effects of carvedilol in patients with moderate to severe heart failure. The PRECISE Trial. Prospective Randomized Evaluation of Carvedilol on Symptoms and Exercise |journal=[[Circulation]] |volume=94 |issue=11 |pages=2793–9 |year=1996 |month=December |pmid=8941104 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8941104 |accessdate=2012-04-05}}</ref><ref name="pmid8941105">{{cite journal |author=Colucci WS, Packer M, Bristow MR, Gilbert EM, Cohn JN, Fowler MB, Krueger SK, Hershberger R, Uretsky BF, Bowers JA, Sackner-Bernstein JD, Young ST, Holcslaw TL, Lukas MA |title=Carvedilol inhibits clinical progression in patients with mild symptoms of heart failure. US Carvedilol Heart Failure Study Group |journal=[[Circulation]] |volume=94 |issue=11 |pages=2800–6 |year=1996 |month=December |pmid=8941105 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8941105 |accessdate=2012-04-05}}</ref><ref name="pmid9033462">{{cite journal |author= |title=Randomised, placebo-controlled trial of carvedilol in patients with congestive heart failure due to ischaemic heart disease. Australia/New Zealand Heart Failure Research Collaborative Group |journal=[[Lancet]] |volume=349 |issue=9049 |pages=375–80 |year=1997 |month=February |pmid=9033462 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673697800086 |accessdate=2012-04-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In [[patients]] with [[HFrEF]], with current or previous [[symptoms]], use of 1 of the 3 [[beta blockers]] proven to reduce [[mortality]] (eg, bisoprolol, carvedilol,sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations. <ref name="pmid10023943">{{cite journal| author=| title=The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. | journal=Lancet | year= 1999 | volume= 353 | issue= 9146 | pages= 9-13 | pmid=10023943 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10023943  }} </ref><ref name="pmid10376614">{{cite journal| author=| title=Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) | journal=Lancet | year= 1999 | volume= 353 | issue= 9169 | pages= 2001-7 | pmid=10376614 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10376614  }} </ref><ref name="pmid12390947">{{cite journal| author=Packer M, Fowler MB, Roecker EB, Coats AJ, Katus HA, Krum H | display-authors=etal| title=Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival (COPERNICUS) study. | journal=Circulation | year= 2002 | volume= 106 | issue= 17 | pages= 2194-9 | pmid=12390947 | doi=10.1161/01.cir.0000035653.72855.bf | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12390947  }} </ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
 
|}
 
{|class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:"White"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class Value Statement: High Value]]
 
|-
|bgcolor="White"|<nowiki>"</nowiki>'''2.''' In [[patients]] with [[HFrEF]], with current or previous [[symptoms]], [[beta blocker]] [[therapy]] provides high economic values. <ref name="pmid23433562">{{cite journal| author=Banka G, Heidenreich PA, Fonarow GC| title=Incremental cost-effectiveness of guideline-directed medical therapies for heart failure. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 13 | pages= 1440-6 | pmid=23433562 | doi=10.1016/j.jacc.2012.12.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23433562  }} </ref><ref name="pmid16360958">{{cite journal| author=Caro JJ, Migliaccio-Walle K, O'Brien JA, Nova W, Kim J, Hauch O | display-authors=etal| title=Economic implications of extended-release metoprolol succinate for heart failure in the MERIT-HF trial: a US perspective of the MERIT-HF trial. | journal=J Card Fail | year= 2005 | volume= 11 | issue= 9 | pages= 647-56 | pmid=16360958 | doi=10.1016/j.cardfail.2005.06.433 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16360958  }} </ref><ref name="pmid10190405">{{cite journal| author=Delea TE, Vera-Llonch M, Richner RE, Fowler MB, Oster G| title=Cost effectiveness of carvedilol for heart failure. | journal=Am J Cardiol | year= 1999 | volume= 83 | issue= 6 | pages= 890-6 | pmid=10190405 | doi=10.1016/s0002-9149(98)01066-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10190405  }} </ref><ref name="pmid11334781">{{cite journal| author=Gregory D, Udelson JE, Konstam MA| title=Economic impact of beta blockade in heart failure. | journal=Am J Med | year= 2001 | volume= 110 Suppl 7A | issue= | pages= 74S-80S | pmid=11334781 | doi=10.1016/s0002-9343(98)00387-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11334781  }} </ref><ref name="pmid11485131">{{cite journal| author=Vera-Llonch M, Menzin J, Richner RE, Oster G| title=Cost-effectiveness results from the US Carvedilol Heart Failure Trials Program. | journal=Ann Pharmacother | year= 2001 | volume= 35 | issue= 7-8 | pages= 846-51 | pmid=11485131 | doi=10.1345/aph.10114 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11485131  }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
 
|}
|}


==External Links==
==External Links==
*[https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000001063.full.pdf 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines]<ref name="pmid35363499">{{cite journal |vauthors=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW |title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=145 |issue=18 |pages=e895–e1032 |date=May 2022 |pmid=35363499 |doi=10.1161/CIR.0000000000001063 |url=}} </ref>
*[http://circ.ahajournals.org/content/112/12/e154.full.pdf The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult] <ref name="Hunt">Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref>
*[http://circ.ahajournals.org/content/112/12/e154.full.pdf The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult] <ref name="Hunt">Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref>


Latest revision as of 20:44, 22 June 2022
Resident
Survival
Guide
File:Critical Pathways.gif

Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure beta blockers On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Congestive heart failure beta blockers

CDC on Congestive heart failure beta blockers

Congestive heart failure beta blockers in the news

Blogs on Congestive heart failure beta blockers

Directions to Hospitals Treating Congestive heart failure beta blockers

Risk calculators and risk factors for Congestive heart failure beta blockers

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [2] and C. Michael Gibson, M.S., M.D. [3], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [4] Mitra Chitsazan, M.D.[5] Edzel Lorraine Co, DMD, MD[6]

Beta Blockers

Indications for Beta Blockers Use

A patient should be administered a "heart failure approved" or "evidence-based " beta blocker (metoprolol succinate[1], carvedilol, bisoprolol) if:

1. The Left Ventricular Ejection Fraction (LVEF) is ≤ 40%

or

2. There is a history of myocardial infarction (MI)[2]

Background


Dosing

Beta Blocker Starting dose Target dose
Bisoprolol 1.25 mg QD 10 mg QD
Carvedilol 3.125 mg BID 50 mg BID
Carvedilol CR 10 mg QD 80 mg QD
Metoprolol succinate (CR/XL) 12.5–25 mg QD 200 mg QD
Nebivolol 1.25 mg QD 10 mg QD

2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [3]

Beta Blockers

Class I
"1. In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (eg, bisoprolol, carvedilol,sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations. [4][5][6](Level of Evidence: A) "
Class Value Statement: High Value
"2. In patients with HFrEF, with current or previous symptoms, beta blocker therapy provides high economic values. [7][8][9][10][11] (Level of Evidence: A) "

External Links

References

  1. ↑ Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P (2000). "Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group". JAMA : the Journal of the American Medical Association. 283 (10): 1295–302. PMID 10714728. Retrieved 2012-04-03. Unknown parameter |month= ignored (help)
  2. ↑ Gottlieb SS, McCarter RJ, Vogel RA (1998). "Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction". The New England Journal of Medicine. 339 (8): 489–97. doi:10.1056/NEJM199808203390801. PMID 9709041. Retrieved 2012-04-03. Unknown parameter |month= ignored (help)
  3. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check |pmid= value (help).
  4. ↑ "The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial". Lancet. 353 (9146): 9–13. 1999. PMID 10023943.
  5. ↑ "Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF)". Lancet. 353 (9169): 2001–7. 1999. PMID 10376614.
  6. ↑ Packer M, Fowler MB, Roecker EB, Coats AJ, Katus HA, Krum H; et al. (2002). "Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival (COPERNICUS) study". Circulation. 106 (17): 2194–9. doi:10.1161/01.cir.0000035653.72855.bf. PMID 12390947.
  7. ↑ Banka G, Heidenreich PA, Fonarow GC (2013). "Incremental cost-effectiveness of guideline-directed medical therapies for heart failure". J Am Coll Cardiol. 61 (13): 1440–6. doi:10.1016/j.jacc.2012.12.022. PMID 23433562.
  8. ↑ Caro JJ, Migliaccio-Walle K, O'Brien JA, Nova W, Kim J, Hauch O; et al. (2005). "Economic implications of extended-release metoprolol succinate for heart failure in the MERIT-HF trial: a US perspective of the MERIT-HF trial". J Card Fail. 11 (9): 647–56. doi:10.1016/j.cardfail.2005.06.433. PMID 16360958.
  9. ↑ Delea TE, Vera-Llonch M, Richner RE, Fowler MB, Oster G (1999). "Cost effectiveness of carvedilol for heart failure". Am J Cardiol. 83 (6): 890–6. doi:10.1016/s0002-9149(98)01066-2. PMID 10190405.
  10. ↑ Gregory D, Udelson JE, Konstam MA (2001). "Economic impact of beta blockade in heart failure". Am J Med. 110 Suppl 7A: 74S–80S. doi:10.1016/s0002-9343(98)00387-8. PMID 11334781.
  11. ↑ Vera-Llonch M, Menzin J, Richner RE, Oster G (2001). "Cost-effectiveness results from the US Carvedilol Heart Failure Trials Program". Ann Pharmacother. 35 (7–8): 846–51. doi:10.1345/aph.10114. PMID 11485131.
  12. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW (May 2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check |pmid= value (help).
  13. ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  14. ↑ Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967

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