Rapid titration of carvedilol in patients with congestive heart failure: a randomized trial of automated telemedicine versus frequent outpatient clinic visits.
BACKGROUND
Because of potential side effects and logistical difficulty of titrating medications, outpatients with congestive heart failure rarely receive appropriate doses of carvedilol or other beta-blockers. To address these obstacles, we studied if an automated telemedicine system named TeleWatch (TW) could facilitate carvedilol titration in outpatients with left ventricular systolic dysfunction.


METHODS
Forty-nine patients with New York Heart Association class II and III left ventricular systolic dysfunction, who were tolerating appropriate afterload-reducing therapy and not receiving beta-blockers, were enrolled into a 3-month study. Patients were randomized to have clinic-only (CO) (n = 24) carvedilol titration or titrations which combined clinic visits with TW monitoring (n = 25). All patients were seen in clinic biweekly, and those in the TW group were remotely monitored daily. Using a predefined algorithm, patients in the CO and TW groups were eligible for carvedilol titration on a biweekly or weekly basis, respectively, by physicians blinded to group assignment.


RESULTS
There was no statistical difference in the mean final daily dose of carvedilol between the CO and TW groups (39.4 vs 36.2 mg/d, P = .52). Because remote telemedicine titrations were as successful as titrations in the clinic, the time to reach the final dose of carvedilol was significantly shorter in the TW group (33.6 vs 63.7 days, P < .0001). There were 5 serious adverse events in the study, 4 of which were in the TW group (P = .29); however, TW prospectively detected 2 adverse events.


CONCLUSIONS
Remote monitoring with an automated telemedicine system can successfully facilitate titration of carvedilol in outpatients with New York Heart Association class II and III congestive heart failure.
Johns Hopkins University, School of Medicine, Baltimore, MD, USA. ekasper@jhmi.edu
Jeffrey
J
Spaeder
Samer S
SS
Najjar
Gary
G
Gerstenblith
Gail
G
Hefter
Linda
L
Kern
James G
JG
Palmer
Sheldon H
SH
Gottlieb
Edward K
EK
Kasper
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000097:blood / Q000627:therapeutic use*; D000328:Adult; D000553:Ambulatory Care; D002227:Carbazoles / Q000008:administration & dosage / Q000097:blood* / Q000627:therapeutic use*; D000077261:Carvedilol; D016903:Drug Monitoring; D005260:Female; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011412:Propanolamines / Q000008:administration & dosage / Q000097:blood* / Q000627:therapeutic use*; D012044:Regression Analysis; D017216:Telemedicine; D017186:Titrimetry
D000319:Adrenergic beta-Antagonists; D002227:Carbazoles; D011412:Propanolamines; D000077261:Carvedilol