β Blockers
1 Carvedilol at a dose > 6.25 mg bid can be considered for all HF patients. Toprol
XL 200 mg qd and bisoprolol 10 mg qd can be considered for patients with
moderate HF.
2 β blockers should not be initiated in patients who are:
a in a fluid overloaded state
b hypotensive (< 80 mm Hg systolic)
c in acute decompensated HF
d have heart block or other conduction abnormalities
3
Prior to initiation of β blockers:
a Review current medications for use of other β blockers (e.g. eye drops).
b Review patient’s medical history for a history of or risk for β blocker
intolerance (COPD, asthma, diabetes, bradycardia, hypotension, etc.).
c Record NYHA classification, LVEF and vital signs.
d Obtain a recent history for worsening HF (edema, weight gain, etc.) to make
sure patient is stable before β blocker initiation.
e Educate the patient that signs and symptoms of HF (dyspnea, edema, etc.)
may become worse during the titration process and usually will subside within
8–10 weeks, but if such symptoms occur, they should call the HF clinic staff.
4 Educate the patient on the possible effects of β blockers on diabetic control,
hyperlipidemia, and pulmonary status, and their need to report changes to the
heart failure team.
Carvedilol Titration
1 Initiation of Coreg (carvedilol) will begin within 3.125 mg bid and will be
doubled every 2 weeks to 6.25 mg bid, 12.5 mg bid, and then to 25 mg bid for
optimal dosing. The target dose is at least 6.25 mg bid. Up-titrate if the patient
has had no exacerbation of symptoms, HR is > 50 bpm and systolic BP is
> 85 mmHg.
2 Goal dosing in heart failure patients:
a Carvedilol 25 mg. bid for patients weighing < 187 lb.
b Carvedilol 50 mg bid for patients weighing > 187 lb.
3 Titration process may be lengthened according to individual patient responses
(fatigue, dyspnea, edema, hypotension and bradycardia). Consider increasing only
the evening dose utilizing a “half step titration” for patients who are poorly
tolerating the titration protocol.
4 For patients not tolerating the β blocker titration:
a Separate the timing of the ACEI dose and β blocker by at least two hours
during the day. Consider a once daily ACEI which can be taken q hs.
b Down-titrate the ACEI or other hypotensive agent.
c Follow weights closely and up- or down-titrate diuretics accordingly.
d Administer carvedilol with food to slow absorption.
5 Instruct the patient not to take the β blocker immediately prior to a clinic visit so
that a dosage adjustment decision may be made and observed in the clinic that
day.
a If the patient does take the β blocker within 2 hours of a titration visit,
administer only 1/2 the new dose for that visit (so that the clinic visit dose and the
Taken from Establishing a Heart Failure Center: The Essential Guide
Third edition, by Michael McIvor
dose already taken by the patient add up to the new dose).
b If the patient takes a β blocker dose within 2-5 hours of a titration visit,
consider rescheduling the visit if the patient has been particularly fragile.
Toprol XL Titration
1 For Toprol XL, begin at 25 mg qd (12.5 mg in more severe HF patients), then
double the dose every two weeks until achieving the target dose of 200 mg/day, or
the maximum dose tolerated.
2 The minimally effective dose is unknown, but is > 100 mg. If intolerable
symptoms (e.g. exacerbation of bronchospastic lung disease, loss of glycemic
control in a brittle diabetic) at sub-target doses of Toprol XL, consider switching
to carvedilol with a target dose > 6.25 mg bid.
Bisoprolol Titration
1 Bisoprolol should be initiated at 1.25 mg qd.
2 Uptitrations can occur every two weeks. The target dose is 10 mg qd. 5 mg qd
may not confer a benefit to HF patients.
3 If intolerable symptoms (e.g. exacerbation of bronchospastic lung disease, loss of
glycemic control in a brittle diabetic) at sub-target doses of bisoprolol, consider
switching to carvedilol with a target dose > 6.25 mg bid.
Taken from Establishing a Heart Failure Center: The Essential Guide
Third edition, by Michael McIvor