How should beta-blockers be prescribed for patients with congestive heart failure?
Evidence-Based Answer:
Beta-blockers should be prescribed at low initial doses and gradually titrated every 2 weeks to research-validated targets or the maximally tolerated dose. Two-thirds of patients will not achieve target doses. (SOR A, based on multiple randomized controlled trials [RCTs].) If worsening of heart failure symptoms occur during titration, the doses of diuretics (SOR B, based on multiple RCTs) or other concomitant medications (SOR C, based on expert opinion) should be adjusted.
Sustained-release metoprolol and immediate-release carvedilol both have a US Food and Drug Administration (FDA) indication for use in heart failure, based on high-quality RCTs.1–4 Bisoprolol has strong supporting evidence for its use and is recommended per guidelines, but has an FDA indication only for hypertension.1,2,5
Two trials used an every 2-week beta-blocker titration schedule (TABLE).3,4 The Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) and the Carvedilol Prospective Randomized Cumulative Survival Study (COPERNICUS) were both large, double-blind, randomized, placebo-controlled heart failure survival studies.3,4 Only 64% and 65.1% of patients, respectively, tolerated titration to target dose.
The Cardiac Insufficiency Bisoprolol Study (CIBIS) III was a large, randomized, open-label, blinded end point evaluation trial.5 CIBIS III evaluated beta-blockers as initial therapy in comparison with angiotensin-converting enzyme inhibitors. A 6-step titration was used. Only 65% of patients tolerated titration to target dose.
The above trials used diuretic adjustment as needed to facilitate beta-blocker titration, but failed to characterize the actual changes in diuretic frequency and/or dose during titration.3–5 Expert opinion suggests increasing diuretic dosing for patients with symptoms of fluid retention or worsening of heart failure.2 The American College of Cardiology/American Heart Association and the Heart Failure Society of America suggest extending beta-blocker titration and making vasoactive medication dose adjustments for patients with bradycardia and hypotension.1,2
HelpDesk Answer From EBP,
Inna Velychko, MD Stephen Thomas, PharmD
Flower Hospital Family Medicine Residency, Sylvania, OH
1. Hunt SA; 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). 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).J Am Coll Cardiol. 2005; 46(6):e1–e82. [LOE 5]
2. Heart Failure Society of America. Executive summary: HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail.. 2006; 12(1):10–38. [LOE 5]
3. Hjalmarson A, Goldstein S, Fagerberg B, et al. 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. 2000; 283(10):1295–1302. [LOE 1b]
4. Packer M, Coats AJ, Fowler MB, et al; for the Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001; 344(22):1651–1658. [LOE 1b]
5. Willenheimer R, van Veldhuisen DJ, Silke B, et al; for the CIBIS III Investigators. Effect on survival and hospitalization of initiating treatment for chronic heart failure with bisoprolol followed by enalapril, as compared with the opposite sequence: results of the randomized Cardiac Insufficiency Bisoprolol Study (CIBIS) III. Circulation. 2005; 112(16):2426–2435. [LOE 1b]
New Tuberculosis Guidelines
Major progress in global tuberculosis control followed the widespread implementation of the DOTS strategy. The Stop TB Strategy, launched in 2006, builds upon and enhances the achievements of DOTS. New objectives include universal access to patient-centred treatment and protection of populations from TB/HIV and multidrug-resistant TB (MDR-TB). The Stop TB Strategy and the Global Plan to implement the new strategy make it necessary to revise the third edition of Treatment of tuberculosis: guidelines for national programmes, published in 2003.
Creation of the fourth edition follows new WHO procedures for guidelines development.
14th FMSA Scientific Conference 2010
This year’s theme is Prevention in Primary Care: The Way Forward.
the objectives
- To encourage preventive-oriented or “proactive” mode of care in order to reduce disease related morbidity and mortality,
- To strengthen and update the knowledge in preventive care for all ages,
- To practice an effective screening for a broad range of risk factors associated with preventable disease and encourage appropriate preventive measure.
Go to Official conference’s website
A Rational Approach to Starting Insulin Therapy
The emergence of multiple insulin products has provided new opportunities to achieve diabetes control. However, the number of options has raised concerns about the optimal choices of products. The purpose of this article to briefly review the pharmacologic characteristics of currently available insulin products and to suggest an initial insulin regimen based on common blood glucose profiles among patients with diabetes.
Several new insulin and insulin analogue preparations are now available for clinical use. Used as prandial insulin (for example, insulin lispro, insulin aspart, or insulin glulisine) and basal insulin (for example, insulin glargine or insulin detemir), the analogues simulate physiologic insulin profiles more closely than the older conventional insulins. There is currently no strong rationale favoring glargine, neutral protamine Hagedorn insulin, insulin detemir, or fixed-ratio insulin preparations as the preferred agent for initiating insulin therapy
90% don’t use condoms
Star: GEORGE TOWN: Some 90% of drug users do not use condoms and this is a source of worry because it can contribute to the rise of HIV/AIDS cases, said social activist Datin Paduka Marina Mahathir.
Marina, an Asia Pacific Leadership Forum on HIV/AIDS steering committee member, said drug users continued to neglect the use of condoms despite the contraceptives being distributed for free by some non-governmental organisations (NGOs).
Read the rest of this entry »
Peadiatric Protocols fo Malaysian Hospitals
This new edition like its predecessor is the result of team work involving
many busy individuals who have none the less found time to meet our printing
dateline.
Read the rest of this entry »
The Power of Sleep
A month ago, many of us heard about the sad demise of Ranjan Das from Bandra, Mumbai. Ranjan, just 42 years of age, was the CEO of SAP-Indian Subcontinent, the youngest CEO of an MNC in India .
Making Primary Care Research Relevant
City Bayview Hotel, Melaka. 5th t0 6th Dec 2009.The Malaysian Primary Care Research Group, of the Academy of Family Physician of Malaysia (AFPM) together with the Ministry of Health Malaysia,
Government to subsidise treatment at private clinics
Health Minister Datuk Seri Liow Tiong Lai says the public can soon seek medical treatment at private clinics without having to pay a hefty sum. The government is considering paying a portion of the bill under a proposed healthcare reform plan.
PHILADELPHIA — November 16, 2009 — In an update to its 2002 recommendations, the US Preventive Services Task Force (USPSTF) now recommends against routine breast cancer screening for women under the age of 50.