Congestive heart failure beta blockers
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Resident Survival Guide |
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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]
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
- 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.
- 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 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.
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 |
2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT) [3][4]
Blockers in Patients Presenting With Heart Failure (DO NOT EDIT) [3][4]
| Class I |
| "1. Beta blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and 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.[5][1][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] (Level of Evidence: A) " |
Vote on and Suggest Revisions to the Current Guidelines
External Links
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [3]
- 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 [4]
References
- ↑ 1.0 1.1 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) - ↑ 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) - ↑ 3.0 3.1 3.2 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
- ↑ 4.0 4.1 4.2 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
- ↑ "The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial". Lancet. 353 (9146): 9–13. 1999. PMID 10023943. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ "A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure". The New England Journal of Medicine. 344 (22): 1659–67. 2001. doi:10.1056/NEJM200105313442202. PMID 11386264. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ 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 (2003). "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". Lancet. 362 (9377): 7–13. doi:10.1016/S0140-6736(03)13800-7. PMID 12853193. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ "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. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Lechat P, Packer M, Chalon S, Cucherat M, Arab T, Boissel JP (1998). "Clinical effects of beta-adrenergic blockade in chronic heart failure: a meta-analysis of double-blind, placebo-controlled, randomized trials". Circulation. 98 (12): 1184–91. PMID 9743509. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH (1996). "The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group". The New England Journal of Medicine. 334 (21): 1349–55. doi:10.1056/NEJM199605233342101. PMID 8614419. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne A, Roecker EB, Schultz MK, DeMets DL (2001). "Effect of carvedilol on survival in severe chronic heart failure". The New England Journal of Medicine. 344 (22): 1651–8. doi:10.1056/NEJM200105313442201. PMID 11386263. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Dargie HJ (2001). "Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial". Lancet. 357 (9266): 1385–90. PMID 11356434. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Cleland JG, Pennell DJ, Ray SG, Coats AJ, Macfarlane PW, Murray GD, Mule JD, Vered Z, Lahiri A (2003). "Myocardial viability as a determinant of the ejection fraction response to carvedilol in patients with heart failure (CHRISTMAS trial): randomised controlled trial". Lancet. 362 (9377): 14–21. PMID 12853194. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Fisher ML, Gottlieb SS, Plotnick GD, Greenberg NL, Patten RD, Bennett SK, Hamilton BP (1994). "Beneficial effects of metoprolol in heart failure associated with coronary artery disease: a randomized trial". Journal of the American College of Cardiology. 23 (4): 943–50. PMID 8106700. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Metra M, Nardi M, Giubbini R, Dei Cas L (1994). "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 of the American College of Cardiology. 24 (7): 1678–87. PMID 7963115. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Olsen SL, Gilbert EM, Renlund DG, Taylor DO, Yanowitz FD, Bristow MR (1995). "Carvedilol improves left ventricular function and symptoms in chronic heart failure: a double-blind randomized study". Journal of the American College of Cardiology. 25 (6): 1225–31. doi:10.1016/0735-1097(95)00012-S. PMID 7722114. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Krum H, Sackner-Bernstein JD, Goldsmith RL, Kukin ML, Schwartz B, Penn J, Medina N, Yushak M, Horn E, Katz SD (1995). "Double-blind, placebo-controlled study of the long-term efficacy of carvedilol in patients with severe chronic heart failure". Circulation. 92 (6): 1499–506. PMID 7664433. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Waagstein F, Bristow MR, Swedberg K, Camerini F, Fowler MB, Silver MA, Gilbert EM, Johnson MR, Goss FG, Hjalmarson A (1993). "Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy. Metoprolol in Dilated Cardiomyopathy (MDC) Trial Study Group". Lancet. 342 (8885): 1441–6. PMID 7902479. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ "A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). CIBIS Investigators and Committees". Circulation. 90 (4): 1765–73. 1994. PMID 7923660. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ 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 (1996). "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". Circulation. 94 (11): 2793–9. PMID 8941104. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ 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 (1996). "Carvedilol inhibits clinical progression in patients with mild symptoms of heart failure. US Carvedilol Heart Failure Study Group". Circulation. 94 (11): 2800–6. PMID 8941105. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ "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". Lancet. 349 (9049): 375–80. 1997. PMID 9033462. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help)