The recommendations presented here are primarily from the observational experience of HF physicians familiar with the use of carvedilol and in switching such patients.
Moreover, the recently completed Carvedilol or Metoprolol European Trial (COMET), designed as a direct comparison between metoprolol and carvedilol demonstrated the superiority of comprehensive adrenergic blockade (carvedilol) vs. BWhether one chooses to switch a hypertension or post‐MI patient who now has clinical HF from an earlier‐generation β blocker to carvedilol or elects to switch a patient with established HF already receiving a βThe use of β blockers in HF is based on the demonstrated deleterious effects of chronic sympathetic activation on the heart, circulation, and kidneys in HF.These concepts were initially supported by the observed beneficial effects of β blockers in small, uncontrolled studies conducted in Sweden in the 1970s on patients with congestive cardiomyopathy.Third‐generation β‐blocking agents are nonselective β blockers with ancillary vasodilating properties.Evidence from RCTs suggests that carvedilol's distinguishing properties may translate into clinical advantages in the treatment of HF. I have read and accept the Wiley Online Library Terms and Conditions of UseCarvedilol produces dose‐related improvements in left ventricular function and survival in subjects with chronic heart failureThe Cardiac Insufficiency Bisoprolol Study II (CIBIS‐II): a randomised trialEffect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT‐HF)The effect of carvedilol on morbidity and mortality in patients with chronic heart failureDouble‐blind, placebo‐controlled study of the effects of carvedilol in patients with moderate to severe heart failure. Unable to load your delegates due to an error In some cases slowing the rate of titration or reducing the dose may also be considered.
doi: 10.1016/S0954-6111(11)70010-5.Jabbour A, Macdonald PS, Keogh AM, Kotlyar E, Mellemkjaer S, Coleman CF, Elsik M, Krum H, Hayward CS.J Am Coll Cardiol.
For completeness, the regimens used in two publications in which switching was performed are also reviewed.The major factors to be kept in mind when switching to carvedilol are maintaining adequate β blockade to avoid the potential for precipitating ischemia or arrhythmias, choosing an initial dose with a low potential for producing any vasodilating side effects (e.g., dizziness or hypotension), and avoidance of changes in HF status due to changes in receptor sensitivity and density.In addition, as in any patient initiating β blockade, adequate treatment with diuretics and ACE inhibitors should be in place and patients should be free of volume overload.
More-over, while some β blockers (carvedilol, bisoprolol, and metoprolol succinate [CR/XL]) reduce mortality and morbidity in HF, others do not (bucindolol, xam-oterol).15,16 Beta blockers are a heterogeneous group of 3.125mg twice daily.
Clinical evidence, as well as physiological considerations, may lead physicians to consider switching β‐blocker therapy to carvedilol in some patients with HF.
Most carvedilol‐related symptoms should be addressed by adjusting the patient's diuretic or ACE inhibitor.
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The successful switch to bisoprolol for the 85 subjects led to a total direct drug cost savings of S$12,321 (US$8730) for these patients.
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Lainscak M, Podbregar M, Kovacic D, Rozman J, von Haehling S.Respir Med. For example, lower doses of metoprolol CR/XL have not been demonstrated to be effective, whereas carvedilol reduces mortality and morbidity across the dose range from 6.25–25.0 mg b.i.d.There may also be important subgroup differences that favor the use of one β‐blocking agent over another.
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