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 |
|
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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 | Copyright© 2016 - 2020 East Lancashire Medicines Management Board | All rights reserved. Disclaimer/Terms and conditions | |