Congestive heart failure beta blockers
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Editor(s)-In-Chief: James Chang, M.D., Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School [2] and C. Michael Gibson, M.S., M.D. [3], Cardiovascular Division Beth Israel Deaconess Medical Center, Boston MA, Harvard Medical School; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [4] Mitra Chitsazan, M.D.[5] Edzel Lorraine Co, DMD, MD[6]
Indications for Beta Blockers Use
A patient should be administered a “heart failure approved” or “evidence-based ” beta blocker (metoprolol succinate[1], carvedilol, bisoprolol) if:
1. The Left Ventricular Ejection Fraction (LVEF) is ≤ 40%
or
2. There is a history of myocardial infarction (MI)[2]
Background
- Blockade of compensatory sympathetic stimulation is associated with arrhythmic, ischemic, remodeling, and apoptotic benefits.
- Used as monotherapy or combined with conventional heart failure management, beta blockers reduce the combined risk of morbidity and mortality.
- Beta blocker therapy is recommended for ANY patient with reduced left ventricular ejection fraction (≤ 40%) regardless of the etiology of left ventricular systolic dysfunction (ischemic or nonischemic) or presence/absence of symptoms. Patients with or without heart failure (in other words, even those with asymptomatic left ventricular systolic dysfunction) are included in this recommendation.
- Beta blockers approved by the FDA for use in the treatment of heart failure are metoprolol succinate and carvedilol. In Europe, bisoprolol is also approved for use in heart failure. In addition, beta blocker therapy is indicated for patients with history of myocardial infarction whether or not left ventricular systolic dysfunction or heart failure is present.
- Beta blocker therapy should be initiated at low dosage and gradually uptitrated, as tolerated, toward target dosages of 200 mg daily for metoprolol succinate and 25 mg twice daily for carvedilol, or to the maximum tolerated dosage.
- Other beta-blockers (such as atenolol) have not been demonstrated to have the same mortality benefits as carvedilol and metoprolol and should not be used for this purpose.
| Beta Blocker | Starting dose | Target dose |
|---|---|---|
| Bisoprolol | 1.25 mg QD | 10 mg QD |
| Carvedilol | 3.125 mg BID | 50 mg BID |
| Carvedilol CR | 10 mg QD | 80 mg QD |
| Metoprolol succinate (CR/XL) | 12.5–25 mg QD | 200 mg QD |
| Nebivolol | 1.25 mg QD | 10 mg QD |
2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [3]
Beta Blockers
| Class I |
| “1. In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (eg, bisoprolol, carvedilol,sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations. [4][5][6](Level of Evidence: A) ” |
| Class Value Statement: High Value |
| “2. In patients with HFrEF, with current or previous symptoms, beta blocker therapy provides high economic values. [7][8][9][10][11] (Level of Evidence: A) ” |
External Links
- 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[12]
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [13]
- 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [14]
References
- ↑ Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P (2000). “Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group”. JAMA : the Journal of the American Medical Association. 283 (10): 1295–302. PMID 10714728. Retrieved 2012-04-03. Unknown parameter
|month=ignored (help) - ↑ Gottlieb SS, McCarter RJ, Vogel RA (1998). “Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction”. The New England Journal of Medicine. 339 (8): 489–97. doi:10.1056/NEJM199808203390801. PMID 9709041. Retrieved 2012-04-03. Unknown parameter
|month=ignored (help) - ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check
|pmid=value (help). - ↑ “The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial”. Lancet. 353 (9146): 9–13. 1999. PMID 10023943.
- ↑ “Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF)”. Lancet. 353 (9169): 2001–7. 1999. PMID 10376614.
- ↑ Packer M, Fowler MB, Roecker EB, Coats AJ, Katus HA, Krum H; et al. (2002). “Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival (COPERNICUS) study”. Circulation. 106 (17): 2194–9. doi:10.1161/01.cir.0000035653.72855.bf. PMID 12390947.
- ↑ Banka G, Heidenreich PA, Fonarow GC (2013). “Incremental cost-effectiveness of guideline-directed medical therapies for heart failure”. J Am Coll Cardiol. 61 (13): 1440–6. doi:10.1016/j.jacc.2012.12.022. PMID 23433562.
- ↑ Caro JJ, Migliaccio-Walle K, O’Brien JA, Nova W, Kim J, Hauch O; et al. (2005). “Economic implications of extended-release metoprolol succinate for heart failure in the MERIT-HF trial: a US perspective of the MERIT-HF trial”. J Card Fail. 11 (9): 647–56. doi:10.1016/j.cardfail.2005.06.433. PMID 16360958.
- ↑ Delea TE, Vera-Llonch M, Richner RE, Fowler MB, Oster G (1999). “Cost effectiveness of carvedilol for heart failure”. Am J Cardiol. 83 (6): 890–6. doi:10.1016/s0002-9149(98)01066-2. PMID 10190405.
- ↑ Gregory D, Udelson JE, Konstam MA (2001). “Economic impact of beta blockade in heart failure”. Am J Med. 110 Suppl 7A: 74S–80S. doi:10.1016/s0002-9343(98)00387-8. PMID 11334781.
- ↑ Vera-Llonch M, Menzin J, Richner RE, Oster G (2001). “Cost-effectiveness results from the US Carvedilol Heart Failure Trials Program”. Ann Pharmacother. 35 (7–8): 846–51. doi:10.1345/aph.10114. PMID 11485131.
- ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW (May 2022). “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check
|pmid=value (help). - ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
- ↑ Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
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