Heart Failure

Only clinicians confident in the management of patients with heart failure should consider beta-blocker initiation.

Although beta-blockers in heart failure have been given a GREEN traffic light by the East Lancashire Medicines Management

Board (ELMMB), those with little experience of managing this patient group should consider referring appropriate patients to the

specialist HF service for advice, in accordance with local referral pathways.

Patients in whom beta-blockers should be initiated with particular caution include:

> Those with reversible airways disease - refer to a HF specialist for advice.

> Those with recent evidence of fluid overload, or patients with repeated episodes of fluid overload - may require

additional diuresis, consider referral to a HF specialist for advice.

Bisoprolol is the preferred agent in primary care, withcarvedilol a suitable second line alternative.

These agents should be initiated at the lowest dose within the dose range. An ECG should be considered before initiation

in patients with a heart rate < 60 beats per minute or where atrial fibrillation is suspected.

The beta-blocker dose should be increased cautiously over a period of three or more months to the maximal tolerated

dose within the dose range, in order to achieve a resting heart rate between 50 and 60 beats per minute. Fluid status,

heart rate and blood pressure should be assessed prior to and following each dose change. Patients may experience

more heart failure-related symptoms during initiation and dose titration of beta-blockers. Additional diuresis may be

required to manage symptoms of fluid overload. Patients should be encouraged to persist with therapy, as evidence

demonstrates improved quality of life in the longer term, as well as reduced mortality and hospitalisation.

NICE Algorithm for the use of beta-blockers in heart failure (ref: NG 106, September 2018)

Confirmed left ventricular systolic dysfunction (Ejection fraction <40% on ECHO)

Step 1 Assess whether suitable for treatment

º Contraindicated in asthma, severe COPD, Heart block, Sick Sinus Syndrome

º Clinically stable Heart Failure (NYAI-VI)

º No signs of sodium and water retention (oedema, lung crackles, raised JVP or congestion on CXR or hepatic congestion)

º Commence on patient who is already receiving diuretic & ACE inhibitor

º If on Beta-blocker for concomitant condition to continue on their current Beta-blocker or one alternatively

licensed for heart failure.

º Heart rate >60 bpm perform ECG

º Systolic BP > 100mmHg

Step 2 - Suitable for Beta-blocker

º Start low and slow

º Monitor heart rate, BP & clinical status (symptoms, signs, especially signs of congestion, body weight)

Step 3 - Two weeks later

º Check blood electrolytes, urea & creatinine 1-2 weeks after initiation and 1-2 weeks after final dose titration.

º Continue to monitor Heart rate, BP, clinical status (symptoms, signs, especially signs of congestion

º Aim for target dose or, failing that, the highest tolerated dose

Bisoprolol dose

> 1.25mg daily for at least one week

> 2.5mg daily for at least one week

> 3.75mg daily for at least one week

> 5mg daily for at least one week

> 7.5mg daily for at least one week

> 10mg thereafter

Carvedilol dose

> 3.125mg twice daily for a minimum of 2 weeks

> 6.25mg twice daily for a minimum of 2 weeks

> 25mg twice daily maintenance for those weighing <85kg & if severe heart failure

> 50mg maintenance dose for those weighing >85kg with mild to moderate heart failure

Advice to patients

> Explain expected benefits

> Emphasise that treatment given as much to prevent worsening of heart failure as to improve symptoms; beta-

blockers also increase survival

> If symptomatic improvement occurs, this will be slowly (3 -6 months)

> Temporary symptomatic deterioration may occur (20-30% cases during initiation/up titration)

Problem solving

> Worsening symptoms/signs (e.g. dyspnoea, fatigue, oedema, weight gain) for immediate review

> If increasing congestion, double dose of diuretic/halve dose of beta-blocker if diuretic does not work

> if marked fatigues and/or bradycardia halve dose of beta-blocker

> Review 1-2 week: if not improved seek specialist advice

> if serious deterioration, before stopping treatment seek specialist advice.

GREEN Bisoprolol tablets 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg

GREEN Carvedilol tablets 3.125mg, 6.25mg, 12.5mg, 25mg

Non-cardiac use: Propranolol is not recommended for cardiac indications but has an application in

management of migraine (see section 4.7)

Empagliflozin for treating chronic heart failure with reduced ejection fraction as by- NICE TA773

1. Empagliflozin is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction

in adults, only if it is used as an add-on to optimised standard care with:

> an angiotensin-converting enzyme (ACE) inhibitor or angiotensin 2 receptor blocker (ARB), with a beta blocker and,

if tolerated, a mineralocorticoid receptor antagonist (MRA), or

> sacubitril valsartan with a beta blocker and, if tolerated, an MRA.

2. Start empagliflozin for treating symptomatic heart failure with reduced ejection fraction on the advice of a heart failure

specialist. Monitoring should be done by the most appropriate healthcare specialist

AMBER Empagliflozin 10mg, 26mg tablets [Jardiance®] CCG Commissioned

Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction as by NICE TA929

> Empagliflozin is recommended, within its marketing authorisation, as an option for treating symptomatic chronic heart

failure with preserved or mildly reduced ejection fraction in adults.

> If people with the condition and their clinicians consider empagliflozin to be 1 of a range of suitable treatments (including

dapagliflozin), after discussing the advantages and disadvantages of all the options, use the least expensive. Take account of

administration costs, dosage, price per dose and commercial arrangements.

AMBER Empagliflozin 10mg, 26mg tablets [Jardiance®] ICB Commissioned

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All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the

public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service

Email: info.elmmb@nhs.net