Beta-blockers heart failure with

I 9 Metra M, Giubbini R, Nodari S, Boldi E, Modena MG, Dei Cas L. Differential effects of beta-blockers in patients with heart failure a prospective, randomized, double-blind comparison of the long-term effects of metoprolol versus carvedilol. Circulation 2000 102 546-551. 

BETA-BLOCKERS LIDOCAINE 1. Risk of bradycardia (occasionally severe), 1 BP and heart failure with intravenous lidocaine 2. Risk of lidocaine toxicity due to t plasma concentrations of lidocaine, particularly with propranolol and nadolol 3. t plasma concentrations of propranolol and possibly some other beta-blockers 1. Additive negative inotropic and chronotropic effects 2. Uncertain, but possibly a combination of beta-blocker-induced reduction in hepatic blood flow (due to 1 cardiac output) and inhibition of metabolism of lidocaine 3. Attributed to inhibition of metabolism by lidocaine 1. Monitor PR, BP and ECG closely watch for development of heart failure when intravenous lidocaine is administered to patients on beta-blockers 2. Watch for lidocaine toxicity 3. Be aware. Regional anaesthetics should be used cautiously in patients with bradycardia. Beta-blockers could cause dangerous hypertension due to stimulation of alpha-receptors if epinephrine is used with focal anaesthetic... 

Hu H, Jui HY, Hu FC et al (2007) Predictors of therapeutic response to beta-blockers in patients with heart failure in Taiwan. J Formos Med Assoc 106 641-648... 

Bohm M, Maack C Treatment of heart failure with beta-blockers. Mechanisms and results. Basic Res... 

The use of beta blockers with felodipine, isradipine, lacidipine, nicardipine, nimodipine and nisoldipine normally appears to be useful and safe. However, severe hypotension and heart failure have occurred rarely when a beta blocker was given with nifedipine or nisoldipine. Changes in the pharmacokinetics of the beta blockers and calcium-channel blockers may also occur on concurrent use, but they do not appear to be clinically important. 

A review of 29 studies (including 19 single-dose studies) on the use of cardioselective beta blockers in patients with reversible airway disease indicated that in patients with mild to moderate disease, the short-term use of cardioselective beta blockers does not cause significant adverse respiratory effects. Information on the effects in patients with more severe or less reversible disease, or on the frequency or severity of acute exacerbations was not available. Another review indicated that when low doses of cardioselective beta blockers are given to patients with mild, intermittent or persistent asthma, or moderate persistent asthma, and heart failure or myocardial infarction, the benefits of treatment outweigh the risks. However,... 

Jabbour A, Macdonald PS, Keogh AM, Kotlyar E, Mellemkjaer S, Coleman CF, Elsik M, Krum H, Hayward CS. Differences between beta-blockers in patients with chronic heart failure and chronic obstructive pulmonary disease a randomized crossover trial. J Am Coll Cardiol 2010 55 1780-8. 

Heart failure-The recommended starting dose is 40 mg twice daily. Up-titrate to 80 and 160 mg twice daily to the highest dose, as tolerated. Consider reducing the dose of concomitant diuretics. The maximum daily dose in clinical trials was 320 mg in divided doses. Concomitant use with an ACE inhibitor and a beta-blocker is not recommended. 

In patients with chronic heart failure, the use of digoxin and beta blockers is typically sufficient to control heart rates, and the combination of digoxin with carvedilol has been shown to provide better overall rate control than either of them used alone in heart failure patients [42]. However, if the patient is either intolerant of beta blockers or they fail to... 

Anonymous. A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure, [see comment]. N. Eng. J. Med. 2001 344 1659-67. 

Beta-blockers can no longer be considered as first line monotherapy for uncomplicated hypertension in older patients since some studies suggest they are less effective than diuretics and no better than placebo in reducing cardiovascular outcomes. Their use in elderly with hypertension probably should be confined to those with other indications such as angina, following myocardial infarction or with heart failure. 

Bnnch TJ, Mnhlestein JB, Bair TL, Renlnnd DG, Lappe DL, Jensen KR et al. Effect of beta-blocker therapy on mortality rates and future myocardial infarction rates in patients with coronary artery disease but no history of myocardial infarction or congestive heart failure. Am J Cardiol 2005 95(7) 827-31. 

The most common side effects are Raynaud s phenomenon with cold or even cyanotic distal extremities and digits, tiredness or weakness, bradycardia, and sexual impotence. Less common side effects are depression and dysphoria, bronchoconstriction, congestive heart failure, hallucinations, hypotension, vomiting or nausea, diarrhea, insomnia and nightmares, dizziness, and hypoglycemia. When due attention is paid to contraindications and the treatment is carefully monitored, the side effects of beta-blocker treatment are generally mild. 

Propranolol was the first blocker shown to be effective in hypertension and ischemic heart disease. Propranolol has now been largely replaced by cardioselective blockers such as metoprolol and atenolol. All B-adrenoceptor-blocking agents are useful for lowering blood pressure in mild to moderate hypertension. In severe hypertension, blockers are especially useful in preventing the reflex tachycardia that often results from treatment with direct vasodilators. Beta blockers have been shown to reduce mortality after a myocardial infarction and some also reduce mortality in patients with heart failure they are particularly advantageous for treating hypertension in patients with these conditions (see Chapter 13). 

Bangalore S et al Beta-blockers for primary prevention of heart failure in patients with hypertension Insights from a meta-analysis. J Am Coll Cardiol 2008 52 1062. [PMID 18848139]... 

In the past, beta blockers were considered detrimental in patients with heart failure.60 As indicated in Chapter 20, these drugs decrease heart rate and myocardial contraction force by blocking the effects of epinephrine and norepinephrine on the heart. Common sense dictated that a decrease in myocardial contractility would be counterproductive in heart failure, and beta blockers were therefore contraindicated in heart failure.60,69 It is now recognized that beta blockers are actually beneficial in people with heart failure because these drugs attenuate the excessive sympathetic activity associated with this disease.56,64 As indicated earlier,... 

Beta blockers bind to beta-1 receptors on the myocardium and block the effects of norepinephrine and epinephrine (see Chapter 20). These drugs therefore normalize sympathetic stimulation of the heart and help reduce heart rate (negative chronotropic effect) and myocardial contraction force (negative inotropic effect). Beta blockers may also prevent angina by stabilizing cardiac workload, and they may prevent certain arrhythmias by stabilizing heart rate.40 These additional properties can be useful to patients with heart failure who also have other cardiac symptoms. 

The side effects and problems associated with beta blockers were addressed in Chapter 20. The primary problem associated with these drugs is that they may cause excessive inhibition of the heart, resulting in an abnormally slow heart rate and reduced contraction force. This effect is especially problematic in heart failure because the heart is already losing its ability to pump blood. Nonetheless, the risk of this and other side effects is acceptable in most people with heart failure, and this risk is minimized by adjusting the dosage... 

---