there is evidence that beta-blockers can improve prognosis in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (1,2)
offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first (3)
offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including (3):
older adults and
patients with:
peripheral vascular disease
erectile dysfunction
diabetes mellitus
interstitial pulmonary disease and
chronic obstructive pulmonary disease (COPD) without reversibility
introduce beta-blockers in a 'start low, go slow' manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker (3)
beta-blocker therapy should be started at a very low dose (e.g. carvedilol 3.125mg once daily) and titrated slowly over a period of weeks or months
the beta-blocker should be up-titrated at fortnightly intervals (or longer in more sensitive patients) to a target dose of carvedilol 25-50mg bd or bisoprolol 10mg od (2,4)
switch stable patients who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure due to left ventricular systolic dysfunction, to a beta-blocker licensed for heart failure
there may be some early symptomatic deterioration during beta-blocker therapy (4)
beta-blockers do not provide an instant beneficial effect in CHF
initially patients may feel more tired and they may experience symptoms of worsening fluid retention requiring a temporary increase in diuretic therapy
beneficial effects on LV function can take 3 to 6 months to appear
Notes:
there is evidence that carvedilol reduced the risk of all cause mortality and combined mortality and general and specific hospital admission in severe heart failure (5) - these results were regardless of pretreatment systolic blood pressure
use of beta-blockers in in patients >/=70 years, regardless of ejection fraction. There is evidence that, in this patient population, nebivolol, a beta-blocker with vasodilating properties, is an effective and well-tolerated treatment for heart failure in the elderly (6)
the magnitude of the prognostic benefit conferred by beta-blockers in the absence of ACE-I appears to be similar to those of ACE-Is in systolic CHF (7)
a meta-analysis has shown that beta-blockers appear to effectively reduce the occurrence of AF in patients with systolic HF (8)
heart rate reduction and beta blockers in heart failure
a meta-analysis (9) found that the extent of heart rate reduction in patients with chronic heart failure treated with beta-blockers was significantly associated with survival benefit in trials, whereas the dose of beta-blocker was not
for every 5 beats/minute reduction in heart rate using beta-blocker treatment, the relative risk of death was decreased by 18%, although the heart rate reduction at which this benefit stops is not known
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