Are Very Important Agents to Use in Chronic HF They Can Have an Extraordinary Impact

MONTEFIORE HEART FAILURE DISEASE MANAGEMENT PROGRAM Heart Failure Center General Outpatient Clinical Recommendations

Beta Blockers

Are very important agents to use in chronic HF –they can have an extraordinary impact!!

Beta Blockers are a key addition to chronic HF therapy and they are still not widely used. A mortality reduction of 34 –65% has been reported when beta blockers are added. Beta blockers have the capacity to reversely remodel (reduce dilatation and decrease hypertrophy) the ventricle particularly in patients whose disease is recent and those with non-ischemic cardiomyopathies. However, the improvement follows true up-titration to target doses. When to use a beta blocker? Patient is not acutely volume overloaded Patient does not have any contraindications, such as acute bronchospasm or marked heart block without an implanted pacemaker or defibrillator. Even in patients with asthma a selective beta blocker may be used. Benefits outweigh the risks Along with other evidence-based HF therapies, such as ACE-Inhibitors

WHICH ONE TO USE? This is not a class effect. Only three beta blockers have been shown to be effective.

· Carvedilol (Coreg ®) · Metoprolol succinate (Toprol XL ®) · Bisoprolol (Zebeta ®)

HOW TO USE AND ADVANTAGES OF EACH: Carvedilol – Begin therapy at 6.25 mg twice a day, increase dose every 2-4 weeks, depending on patient status. The target dose is 25mg twice a day (50 mg bid if >85 kg). A once daily formulation, Coreg CR, is also available and should be initiated at 10 mg daily with a target dose of 80 mg once daily. Advisable to give with food to reduce orthostatic effect. Metoprolol Succinate (Toprol XL)- Metoprolol succinate is a cardio selective beta blocker. Dose should be taken with food. Initiate therapy with 25mg once daily, or 12.5 in the more decompensated patients; increase dose gradually daily every 2-4 weeks to target dose of 200mg daily. Short acting metoprolol tartrate has not been shown to have the same benefit. Metoprolol succinate will not lower blood pressure as much as carvedilol. In patients with borderline blood pressures, it may be a better drug. Bisoprolol- Bisoprolol is a cardio selective beta blocker. Dose should be taken with food. Initiate therapy with 2.5mg once daily; increase dose every 2-4 weeks to target does of 10 mg daily.

General Recommendations for Beta Blocker use in HF patients:

Þ If the patient is on a non-recommended beta blocker, should switch to one of the recommended beta blockers. Þ Lung disease is not an absolute contraindication to beta blockers. If lung function tests do not indicate reactive airway disease, and if the patient is not actively wheezing, beta blockers should not pose a problem. If concerned about lung disease, choose metoprolol succinate or bisoprolol since they are cardio selective. Þ Continuous up titration to target dosing is a key mainstay of HF treatment even if the patient is feeling fine and should only be limited by SBP < 90 mmHg or symptoms (e.g. dizziness) Þ During periods of HF decompensation, BB should be continued. If the patients are severely hypotensive, BB may need to be withheld temporarily. In those cases, the patient should be on the HF service or in CCU. The Guidelines recommend continuation of background therapy when the patient is admitted.

Revised 04/2014