These include its early initiation during a hospitalisation for HF. A strategy of predischarge initiation of beta-blocker therapy was associated with a higher percentage of patients on beta-blockers It is now essential to extend beta-blocker therapy to the largest number of patients with HF, including the elderly and the patients with comorbidities.
To achieve this, it is important that disease management systems which could allow the initiation and uptitration of treatment be established. To date, beta-blockers are the most effective agents to improve LV function and prognosis of the patients with chronic HF. These drugs act on the intrinsic mechanisms causing LV dysfunction - thus their effects emerge slowly though they are then maintained, and even enhanced, in the long-term. Bisoprolol, carvedilol and metoprolol succinate have all been associated with a reduction in mortality and hospitalisations, compared with placebo.
Nebivolol has also improved the outcome in elderly patients with chronic HF. As important differences exist between different beta-blockers, only the agents shown to be effective in randomised trials should be administered.
The administration of beta-blocker therapy to the largest number of patients and their titration up to the target doses shown to be effective should be primary aims in the treatment of patients with HF.
Marco Metra ,. Savina Nodari ,. Livio Dei Cas ,. Citation: European Cardiology ;1 1 Open access: The copyright in this work belongs to Radcliffe Medical Media. The long-term improvement in left ventricular LV function and prognosis after beta-blocker treatment definitively showed that: HF is a progressive disease whose long-term clinical course may be changed; and the excessive cardiac sympathetic drive, rather then abnormal haemodynamics, was the main determinant of the clinical course.
Implementing Beta-blocker Treatment - Treating Co-morbidities and Disease Management Programmes Beta-blockers now have a pivotal role in the treatment of chronic HF; ,5,41 however, they are still significantly underused.
Conclusions To date, beta-blockers are the most effective agents to improve LV function and prognosis of the patients with chronic HF. Available at: www. Heart J. Angiotensin Aldosterone Sys. Impact on treatment strategies, Eur. Heart Fail. Crossref PubMed Norwegian Multicentre Group, Timolol induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction, N. Crossref PubMed Metra M, Nardi M, Giubbini R, Dei Cas L, Effects of short- and long-term carvedilol administration on rest and exercise hemodynamic variables, exercise capacity and clinical conditions in patients with idiopathic dilated cardiomyopathy, J.
They are effective in the control of ventricular arrhythmias related to sympathetic activation, acute coronary syndrome, and heart failure; including the prevention of sudden cardiac death [1]. Contraindications and side effects The most frequent side effects of beta-blockers include: hypotension, bradycardia, bronchospasm, cold extremities, fatigue, headache, sleep disturbances and increased insulin resistance [1].
High-degree AV block is an absolute contraindication if no pacemaker [1]. Use cardioselective beta-blockers in case of chronic obstructive pulmonary disease COPD ; start low and go slow [1]. Asthma is a relative contraindication for the use of beta-blockers [4]. These drugs should be used with caution and preferably with specialist advice. Types and typical dosages of the most frequently used beta-blockers [1].
Most evidence for the reduction of cardiovascular events by beta-blockers concerns acute coronary syndrome patients; especially in the presence of LV dysfunction. High-degree AV block without a pacemaker is an absolute contraindication. Asthma is a relative contraindication. COPD is a relative contraindication. Start low and go slow with the elderly, COPD, and patients with heart failure. The most frequent side effects include: hypotension, bronchospasm, central effects, and increased insulin resistance.
Finally, other causes of hypotension should be considered, such as worsening fluid status caused by increased intake of salt or medication nonadherence. A list of specific tasks for baseline and follow-up office visits is shown in BOX 2.
When hypotension or other adverse effects arise, the clinician can use the flow sheet to determine whether dose titration may have been too rapid or remind the clinician when several previous dose reductions had been necessary. Care can then be monitored sequentially for effectiveness of the change. Although some clinics may not have the resources to provide specific heart failure case management or elaborate quality improvement projects, clinicians can still adopt this approach of small, feasible changes.
An initial first step might be to place a prominent heart failure sticker and the flow sheet in Figure 2 in the charts of all heart failure patients, regardless of whether they have recently been treated in the office. A nurse or office manager can go through the list of heart failure patients, calling in each one for an assessment visit throughout a 2- or 3-month period.
Follow-up can be systematized with the flow sheet in Figure 2. After a 6-month period, the clinician can ask that a sample of heart-failure—labeled charts be pulled for a simple self-directed audit. The point is that adherence to the new guideline will require a system that ensures that eligible patients are identified and appropriately treated.
Other patients' heart failure may progress because of worsened hypertension or myocardial ischemia. You receive a call from the inpatient residents about a year-old man with heart failure admitted to the hospital. He now presents with dyspnea at rest, orthopnea, and peripheral pitting edema after dietary indiscretion while on vacation.
He has no chest pain, and 2 sets of laboratory and electrocardiogram test results show no evidence of ischemia. This patient has experienced an exacerbation of heart failure with evidence of fluid overload. A cardiologist will become involved at some level in the care of patients who require echocardiography or catheterization.
A heart failure specialist should evaluate patients who fail to respond to diuretics or have multiple exacerbations. In addition, many heart failure patients with exacerbation, such as this patient, will benefit from renewed education or participation in a disease-management program, services that may be provided more efficiently in a heart failure specialist clinic. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue.
Figure 1. Figure 2. Effects of beta-adrenergic blockade on the cardiac response to maximal and submaximal exercise in man. J Clin Invest. Google Scholar. The negative inotropic effect of adrenergic betareceptor blocking drugs on human heart muscle.
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Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Dargie HJ. A randomized trial of propranolol in patients with acute myocardial infarction, II: morbidity results. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. Effect of carvedilol on LV function and mortality in diabetic versus non-diabetic patients with ischemic or non-ischemic dilated cardiomyopathy.
Beta-blocker therapy for secondary prevention of myocardial infarction in elderly diabetic patients: results from the National Cooperative Cardiovascular Project. Effectiveness of beta-blocker therapy after acute myocardial infarction in elderly patients with chronic obstructive pulmonary disease or asthma. Baseline predictors of tolerability to carvedilol in patients with chronic heart failure. Owen A. Experience of commencing carvedilol in elderly patients with heart failure in a routine outpatient clinic.
Eur J Heart Fail. National use and effectiveness of beta-blockers for the treatment of edlerly patients after acute myocardial infarction: National Cooperative Cardiovascular Project.
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