Practical considerations for switching beta-blockers in heart failure patients.
The use of beta-blocker therapy has proven extremely useful in a variety of clinical settings, including the management of hypertension, acute- and post-myocardial infarction, and in congestive heart failure (HF). However, there are noticeable differences among individual beta-blockers in regard to efficacy of treatment and clinical outcomes in many of these conditions. These differences are particularly apparent in the treatment of HF, where effects on reverse remodeling and interactions on the periphery are potential factors that can differentiate between the efficacy of one drug versus another. In fact, beta-blockers are not a singular, homogeneous group, but rather a class made up of a number of agents with individual differences in pharmacology, receptor biology, hemodynamic effects, and tolerability. In the event of ongoing disease progression, the onus of choosing the most appropriate beta-blocker falls on the clinician's shoulders. Given the baseline differences among medications of this class, the rationale and manner for transitioning to a different beta-blocker should take into account the specific receptor-blockade subtype of any given agent, as well as any other intrinsic effects attributed to a specific drug. This article includes 2 protocols for switching between carvedilol, a third generation non-selective agent with vasodilatory properties through a1-blockade, and a beta1-selective agent (e.g., metoprolol, atenolol). The aim is to simplify and maximize the safety and tolerability of performing this exchange. With the increasing amount of clinical evidence supporting the use of one beta-blocker over another in the treatment of HF, it behooves physicians treating this patient population to utilize the adrenergic blocking agent that provides optimal therapy with minimal side effects and intolerability.
Abraham
William T
WT
Division of Cardiovascular Medicine, Davis Heart & Lung Research Institute, Ohio State University Heart Center, Columbus, Ohio, USA.
Iyengar
Srinivas
S
D000319:Adrenergic beta-Antagonists / Q000494:pharmacology / Q000627:therapeutic use*; D002227:Carbazoles / Q000494:pharmacology / Q000627:therapeutic use*; D000077261:Carvedilol; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D011412:Propanolamines / Q000494:pharmacology / Q000627:therapeutic use*
D000319:Adrenergic beta-Antagonists; D002227:Carbazoles; D011412:Propanolamines; D000077261:Carvedilol