Tips on beta blocker treatment

• Who should be treated: All NYHA I - IV with LVEF <40%. Any age.
• Prescribe only those with proved benefit from randomized trials, despite the cost.
• Do not hesitate in DM or COPD (unless there is asthma or reactive airway disease), peripheral vascular disease.
• Explain to the patient and the family for cooperation and motivation:
  • How important this medicine is.
  • It may take longer than few months before they feel better from this treatment.
  • Potential side effects and how to treat them.
• Start:
  1. Hospitalized patient.
  • COPERNICUS trial.
  • Patient is stable.
  • 5 - 7 days after intravenous inotropic use for acute decompensation.
  • IMPACT-HF trial.
  • It is safe to initiate the first dose of beta blocker at least 12 hours before discharge in stable heart failure patients.
• Only carvedilol was used in both COPERNICUS and IMPACT-HF trial.
2. Outpatient
• Diurese until patient has no fluid retention or has minimal fluid retention first.
• Prefer to have systolic BP >90. Heart rate >60.
• Do not have to wait until ACEI reach target dose. Adding beta blocker to low dose of ACEI is more benefit than increasing dose of ACEI to a higher one first.
• Starting dose.
  • Carvedilol (Coreg) 3.125 mg bid.
  • Metoprolol Succinate CR (Toprol XL) 12.5 mg daily.
  • Bisoprolol (Zebeta) 1.25 mg daily.
• Upward titration
• Doubling the dose in 2 weeks interval or until side effect resolved.
• If low dose is the only option, only Carvedilol (Coreg) at 6.25 mg bid has proved effective.
• Monitoring the side effects:
  • Usually occurs within the first 2-6 weeks, including during upward titration.
• Weight daily. Increasing weight early is managed by adjust diuretic dose.
• Dizziness or symptomatic hypotension. May give ACEI or other medicine that effect BP at different time, lower the ACEI dose or use low dose (Carvedilol). Correct other causes of dizziness or hypotension.
• Fatigue. May use low dose (Carvedilol).
• Bradycardia or heart block. D/C digitalis (less important than beta blocker), reduce the amiodarone dose, if safe, use low dose (Carvedilol), or implant the pacemaker
• Long term.
  • Patient may not feel better for several months, yet beta blocker may prolong life. Adverse effects are uncommon during long term treatment. Recurrent heart failure is usually due to progression of the disease.
• When should beta blocker be hold or DC
  • Cardiogenic shock and the patient has signs of hypoperfusion.
  • BP < 80 mmHg. However some patients tolerate BP lower than this.
  • Symptomatic bradycardia, 2nd and 3rd degree block, unless pacemaker is inserted.
  • Severe reactive air way condition.
  • Try not to discontinue beta blocker in the patient who has been on it and was admitted for treatment of acute heart failure exacerbation unless it is absolutely necessity.