title: Remote titration of carvedilol for heart failure patients by advanced practice nurses.
abstract: BACKGROUND
  beta-blockers (BB) in the treatment of heart failure (HF) are frequently underprescribed and underdosed, perhaps because of recommendations for office visits at each dose change. In previous work, we demonstrated the feasibility of remote telephonically assisted BB titration and found favorable effects on morbidity, time to target dose, and low withdrawal rates. In the current expanded evaluation, we reasoned that a structured remote telephonic titration protocol would achieve outcomes comparable to US Carvedilol Trials in regard to optimal dose, titration time, and morbidity.
  
  
  METHODS
  Seventy HF patients were initiated on BB therapy (carvedilol). Before therapy, patients were instructed on BB side effects, pulse taking, and weight monitoring. Patients reported weights, vital signs, and symptoms 3 times per week by phone. Advanced practice nurses counseled, educated, and reminded patients to increase their dose every 2 weeks until target doses were reached.
  
  
  RESULTS
  A total of 96% reached a therapeutic dose (6.25 mg twice daily). Moreover, 71% of patients reached target doses of 25 mg twice weekly in approximately 8 weeks. No HF hospitalizations occurred during remote titration.
  
  
  CONCLUSIONS
  The use of advanced practice nurses, titration protocols, and telemanagement technologies may improve the number of HF patients initiated and treated with appropriate doses of BB.
authors.affiliation: Evanston Northwestern Healthcare, Evanston, Illinois 60201, USA.
authors.forename: Deborah
authors.initials: D
authors.lastname: Moyer-Knox
authors.forename: Teresa M
authors.initials: TM
authors.lastname: Mueller
authors.forename: Karen
authors.initials: K
authors.lastname: Vuckovic
authors.forename: Lisa
authors.initials: L
authors.lastname: Mischke
authors.forename: Randall E
authors.initials: RE
authors.lastname: Williams
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D000368:Aged; D001919:Bradycardia / Q000453:epidemiology; D002227:Carbazoles / Q000008:administration & dosage* / Q000009:adverse effects; D000077261:Carvedilol; D002985:Clinical Protocols; D015331:Cohort Studies; D004244:Dizziness / Q000453:epidemiology; D005221:Fatigue / Q000453:epidemiology; D005240:Feasibility Studies; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000451:nursing*; D006801:Humans; D007022:Hypotension / Q000453:epidemiology; D008297:Male; D009722:Nurse Practitioners; D010043:Outcome and Process Assessment, Health Care; D011412:Propanolamines / Q000008:administration & dosage* / Q000009:adverse effects; D017216:Telemedicine; D014481:United States / Q000453:epidemiology
chemical_list: D000319:Adrenergic beta-Antagonists; D002227:Carbazoles; D011412:Propanolamines; D000077261:Carvedilol