Practical Tips in Practical Tips in β β -blocker Therapy in CHF -blocker Therapy in CHF CMCC 11 CMCC 11 th th 11 11 th th September 2009 September 2009 Rungsrit Kanjanavanit MD. Rungsrit Kanjanavanit MD. Cardiovascular Div. Dept. of Medicine Cardiovascular Div. Dept. of Medicine Faculty of Medicine , Chiang Mai Univ. Faculty of Medicine , Chiang Mai Univ.
47
Embed
Practical Tips in β-blocker Therapy in CHF β-blocker Therapy in CHF CMCC 11 th 11 th September 2009 Rungsrit Kanjanavanit MD. Cardiovascular Div. Dept.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Practical Tips inPractical Tips in
ββ-blocker Therapy in CHF-blocker Therapy in CHFCMCC 11CMCC 11thth 11 11thth September 2009 September 2009
Rungsrit Kanjanavanit MD. Rungsrit Kanjanavanit MD. Cardiovascular Div. Dept. of MedicineCardiovascular Div. Dept. of Medicine
Faculty of Medicine , Chiang Mai Univ. Faculty of Medicine , Chiang Mai Univ.
Circulation. 2009;119:1977-2016.
25512551
βB/ ARB
Utilization of HF medications in clinical practiceUtilization of HF medications in clinical practiceEuro Heart SurveyEuro Heart Survey
87
62
37 36 33
21 21 17
0102030405060708090
100
Komajda M et al. Eur Heart J 2003
%
Trials excluded patients with relative contraindications
Not very old , mainly white men, no complicated medical history
In real life , more than 75% have at least one relative contraindication
Clinical trials VS Real world populationClinical trials VS Real world population
4. Digoxin (0.25) ½ tab E.O.D.4. Digoxin (0.25) ½ tab E.O.D.
5. Furosemide (40) 1 tab prn for 5. Furosemide (40) 1 tab prn for dyspnea ,edema or weight gain dyspnea ,edema or weight gain > 1 kg in 2 days> 1 kg in 2 days
13. Warfarin (3) ½ tab o OD. 13. Warfarin (3) ½ tab o OD. Except Mon. and Wed.Except Mon. and Wed.
14.14. Warfarin (5) ½ tab o OD. Warfarin (5) ½ tab o OD. Only on Mon. and Wed.Only on Mon. and Wed.
12. Atrovastatin (20) 1 tab pc evening12. Atrovastatin (20) 1 tab pc evening
Drugs Prescriptions of Mr. Had-enoughDrugs Prescriptions of Mr. Had-enough
POLYPHARMACYPOLYPHARMACY
17. Omeprazole (20) 1 tab o OD17. Omeprazole (20) 1 tab o OD
Patients with Sys HF
Patients with Sys HF without contraindication to β-blocker
Patients with Sys HF who are
given β-blocker( Doctor adherence to guideline)
Patients with Sys HF who are
actually taking β-blocker( Patients’ medical adherence )
Patients with Sys HF who are taking β-blocker at the target dose
We can do We can do better ! better !
ββ blocker in heart failure blocker in heart failure
Contra-indication Strong indication
Tip # 1Tip # 1Implementation of Implementation of β blocker β blocker therapy -When?therapy -When?
A simplified criteria
1. Edema free
2. Not requiring intravenous
medication for HF
Which and what doseWhich and what dose
Starting dose(mg) Target dose(mg)
Bisoprolol 1.25 od 10 od
Metroprolol CR/XL 12.5-25 od 200 od
Carvedilol 3.125 bid 25-50 bid
Nebivolol 1.25 od 10 od
Titration period – weeks to monthsTitration period – weeks to months
Tip # 2 How to use Tip # 2 How to use ββ blocker blocker
Start early but with low dose
Double dose at not less than 2 weekly interval
Aim for target dose or highest tolerated dose
Some β blocker is better than no β blocker
Monitor HR,BP,BW and signs of congestion
Check blood chemistry 1-2 week after inhibition
and 1-2 week after final dose titration
Dry and Dry and WarmWarm
Wet and Wet and WarmWarm
Dry and Dry and ColdCold
Wet and Wet and ColdCold
Fluid statusFluid statusP
erfu
sion
Per
fusi
on
Dry Wet
Warm
Cold
Tip # 3Tip # 3Patient came in with decompensated HF Patient came in with decompensated HF
What to doWhat to do
Wet and warm IV diuretics No need to decrease dose of β-blocker Up-titrate dose of ACEi and β-blocker when stabilized
Wet and cold Positive inotropic support (PDE inhibitors) Decrease the dose of β-blocker by 50% Reintroduction or up-titrate β-blocker when stabilized
B-CONVINCEDB-CONVINCEDBeta-blocker CONtinuation Vs. INterrupion in Beta-blocker CONtinuation Vs. INterrupion in
patients with Congestive heart failure hospitalizED patients with Congestive heart failure hospitalizED for a decompensation episodefor a decompensation episode EHJ (2009) 30,1-7EHJ (2009) 30,1-7
During ADHF, continuation of β-blocker is not associated with delayed or lesser improvement, but with higher rate of chronic prescription of β-blocker therapy after 3 months
Keepβ-blocker
Stopβ-blockerADHF
69
78
HF improves at Day 3
92.8 %
92.3 %
β-blocker at 3 months
90 %
76 %
Plasma BNP, LOS, rehospitalization rate, death rate also similar
Tip # 4 How to use DiureticsTip # 4 How to use Diuretics
Lower the dose or stop before initiation of
ACEi and spironolactone
(avoid hypovolemia )
Increase the dose before initiation of
β- blocker
( make sure there is no fluid retention )
The most important tool in HF managementThe most important tool in HF management
Combined use of low doses of several drugs is preferred to a large dose of a single agent.
Tip # 9 Tip # 9
Six patterns of taking medication among patients treatedSix patterns of taking medication among patients treatedfor chronic illnesses for chronic illnesses who continue to take their medicationswho continue to take their medications
perfect adherence
some timing irregularity
miss an occasional single day’s dose
drug holidays three to four times a year
drug holiday monthly or more
take few or no doses
1/6
1/6
1/6
1/6
1/6
1/6
N Engl J Med 2005;353:487-97
“ Good drugs do not work on patients who do not take them ”