Treatment of chronic heart failure with carvedilol in daily practice: the SATELLITE survey experience

Clinical tolerability of generic versus brand beta blockers in heart failure with reduced left ventricular ejection fraction: a retrospective cohort from heart failure clinic

Background: Beta-blockers have been shown to decrease mortality and morbidity in heart failure with reduced ejection fraction (HFrEF) patients. However, the side effects are also dose-related, leading to the underdosing. Cost constraint may be one of the limitations of appropriate beta-blocker use; this can be improved with generic drugs. However, the effects in real life practice have not been investigated. Methods and results: This study aimed to compare the efficacy and safety of generic and brand beta-blockers in HFrEF patients. We performed a retrospective cohort analysis in HFrEF patients who received either generic or brand beta-blocker in Chiang Mai Heart Failure Clinic. The primary endpoint was the proportion of patients who received at least 50% target dose of beta-blocker between generic and brand beta-blockers. Adverse events were secondary endpoints. 217 patients (119 and 98 patients received generic and brand beta-blocker, respectively) were enrolled. There were no differences between groups regarding age, gender, etiology of heart failure, New York Heart Association (NYHA) functional class, left ventricular ejection fraction (LVEF), rate of receiving angiotensin converting enzyme inhibitor (ACEI), angiotensin recepter blocker (ARB), or spironolactone. Patients receiving brand beta-blockers had lower resting heart rate at baseline (74.9 and 84.2 bpm, p = .001). Rate of achieved 50% target dose and target daily dose did not differ between groups (40.4 versus 44.5% and 48.0 versus 55.0%, p > .05, respectively). Rate of side effects was not different between groups (32.3 versus 29.5%, p > .05) and the most common side effect was hypotension. Conclusion: This study demonstrated that beta-blocker tolerability was comparable between brand and generic formulations. Generic or brand beta-blockers should be prescribed to HFrEF patients who have no contraindications.

Evidence-Based Therapy and Its Association With Workforce Detachment After First Hospitalization for Heart Failure

OBJECTIVES

This study investigated the association between the use of evidence-based medicine (EBM) for heart failure (HF) and risk of workforce detachment.

BACKGROUND

The ability to work can be a marker of functional capacity and quality of life.

METHODS

We examined a nationwide cohort of patients in the workforce 1 year after first hospitalization for HF. EBM was defined as treatment with β-blockers and renin angiotensin system inhibitors. The fraction of target dose (0 TO 1) for each drug was calculated. The sum of the fractions gave each patient a score between 0 and 2. Patients were stratified into 4 groups according to this score: group 4 score = 2 (target dose of both drugs); group 3 score <2 to >1; group 2 score ≤1 to >0.5; and group 1 score ≤0.5. The risk of subsequent workforce detachment was estimated in cause specific Cox regression models.

RESULTS

One year after first HF hospitalization, 10,185 patients were part of the workforce, and 7,561 (74%) were in treatment with at least 1 of the components of EBM. During a median follow-up of 727 days, 2,698 individuals (36%) became detached from the workforce. Patients receiving more EBM had a significantly lower risk of workforce detachment compared with those receiving less EBM (group 4 hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.77 to 0.98; group 3 HR: 0.85; 95% CI: 0.77 to 0.94; and group 2 HR 0.92; 95% CI: 0.83 to 1.02), all compared to group 1.

CONCLUSIONS

Patients in the workforce 1 year after first HF hospitalization and treated with target or near-target doses of EBM were associated with a significantly lower risk of subsequent workforce detachment.

The Pharmacokinetic Interaction Study between Carvedilol and Bupropion in Rats

BACKGROUND/AIMS

The effects of multiple-dose bupropion on the pharmacokinetics of single-dose carvedilol were investigated in order to evaluate this possible drug-drug interaction.

METHODS

A preclinical study was conducted among white male Wistar rats. Each rat was cannulated on the femoral vein prior to being connected to BASi Culex ABC®. During the reference period, each rat received an intravenous and an oral dose of 3.57 mg/kg body weight (b.w.) carvedilol, at 2 days distance. After 5 days of pretreatment with 21.42 mg/kg b.w. bupropion (by oral route, twice a day - given in order to reach the steady state), during the sixth day, 3.57 mg/kg b.w. carvedilol and 21.42 mg/kg b.w. bupropion were orally co-administrated (test period). After each administration of carvedilol, several samples of 200 µL blood were collected. The pharmacokinetic parameters of carvedilol were analyzed by the noncompartmental method.

RESULTS

The 5 days pretreatment with bupropion increased the exposure to carvedilol in rats by 180%, considering the modifications observed in the area under the curve of carvedilol. Carvedilol was shown to have higher plasma concentrations, delay in maximum concentration, and a prolonged half-life, after being pretreated with bupropion.

CONCLUSION

The administration of multiple-dose bupropion influences the pharmacokinetics of carvedilol (single oral dose) in rats.

Expert Comment: Is Medication Titration in Heart Failure too Complex?

Large-scale randomised controlled trials (RCTs) have demonstrated that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and beta-blockers decrease mortality and hospitalisation in patients with heart failure (HF) associated with a reduced left ventricular ejection fraction. This has led to high prescription rates; however, these drugs are generally prescribed at much lower doses than the doses achieved in the RCTs. A number of strategies have been evaluated to improve medication titration in HF, including forced medication up-titration protocols, point-of-care decision support and extended scope of clinical practice for nurses and pharmacists. Most successful strategies have been multifaceted and have adapted existing multidisciplinary models of care. Furthermore, given the central role of general practitioners in long-term monitoring and care coordination in HF patients, these strategies should engage with primary care to facilitate the transition between the acute and primary healthcare sectors.

Potential drug-drug interactions in hospitalized patients with chronic heart failure and chronic obstructive pulmonary disease

INTRODUCTION

Polypharmacy is common in patients with chronic heart failure (HF) and/or chronic obstructive pulmonary disease (COPD), but little is known about the prevalence and significance of drug-drug interactions (DDIs). This study evaluates DDIs in hospitalized patients.

MATERIAL AND METHODS

We retrospectively screened medical charts over a 6-month period for diagnosis of chronic HF and/or COPD. Potential DDIs were evaluated using Lexi-Interact software.

RESULTS

Seven hundred and seventy-eight patients were included in the study (median age 75 years, 61% men). The median number of drugs on admission and discharge was 6 (interquartile range (IQR) 4-9) and 7 (IQR 5-), respectively (p = 0.10). We recorded 6.5 ±5.7 potential DDIs per patient on admission and 7.2 ±5.6 on discharge (p = 0.2). From admission to discharge, type-C and type-X potential DDIs increased (p < 0.05 for both). Type X interactions were rare (< 1%), with the combination of a β-blocker and a β2 agonist being the most common (64%). There were significantly more type-C and type-D potential DDIs in patients with chronic HF as compared to patients with COPD (p < 0.001). Patients with concomitant chronic HF and COPD had more type-C and type-X potential DDIs when compared to those with individual disease (p < 0.005). An aldosterone antagonist and ACE inhibitor/ARB were prescribed to 3% of chronic HF patients with estimated glomerular filtration rate < 30 ml/(min × 1.73 m(2)).

CONCLUSIONS

The DDIs are common in patients with chronic HF and/or COPD, but only a few appear to be of clinical significance. The increase in potential DDIs from admission to discharge may reflect better guideline implementation rather than poor clinical practice.

Aerobic exercise prescription in patients with chronic heart failure: a review in the beta-blocker era

Aerobic exercise training is a well-established nonpharmacological tool in patients with clinically stable chronic heart failure. In recent years, β-blocker therapy has become a primary pharmacologic intervention in patients with chronic heart failure. Despite the undeniable improvements in patients, the β-blocker era has aroused uncertainties about aerobic exercise intensity prescription. It is well known that aerobic exercise prescription is performed by a percentage of the patient's heart rate reserve and the use of β-blockers could interfere in this method. For this reason, the aim of this review is to provide an update about aerobic exercise prescription in patients with chronic heart failure who are using β-blockers.

Use of carvedilol in hypertension: an update

β-blockers are effective antihypertensive agents and, together with diuretics, have been the cornerstone of pioneering studies showing their benefits on cardiovascular morbidity and mortality as a consequence of blood pressure reduction in patients with hypertension. However, evidence from recent meta-analyses have demonstrated no benefit afforded by atenolol compared with placebo in risk of mortality, myocardial infarction, or stroke, and a higher risk of mortality and stroke with atenolol/propranolol compared with other antihypertensive drug classes. Thus, the effect of these agents on cardiovascular morbidity and mortality in hypertensive patients, especially their use in uncomplicated hypertension, has remained largely controversial. However, it is recognized that the clinical studies used in these meta-analyses were mainly based on the older second-generation β-blockers, such as atenolol and metoprolol. Actually, considerable heterogeneity in, eg, pharmacokinetic, pharmacological, and physicochemical properties exists across the different classes of β-blockers, particularly between the second-generation and newer third-generation agents. Carvedilol is a vasodilating noncardioselective third-generation β-blocker, without the negative hemodynamic and metabolic effects of traditional β-blockers, which can be used as a cardioprotective agent. Compared with conventional β-blockers, carvedilol maintains cardiac output, has a reduced prolonged effect on heart rate, and reduces blood pressure by decreasing vascular resistance. Studies have also shown that carvedilol exhibits favorable effects on metabolic parameters, eg, glycemic control, insulin sensitivity, and lipid metabolism, suggesting that it could be considered in the treatment of patients with metabolic syndrome or diabetes. The present report provides an overview of the main clinical studies concerning carvedilol administered as either monotherapy or in combination with another antihypertensive or more frequently a diuretic agent, with particular focus on the additional benefits beyond blood pressure reduction.

Heart failure treatment in the elderly

Heart failure is a growing epidemic, particularly in the elderly. As a consequence, we will see a greater number of elderly patients with heart failure in our practices. Elderly heart failure patients have not been well studied. Data suggest that most medical and other therapies are appropriate for elderly individuals. This article identifies the available data regarding treatment of heart failure in elderly patients.

Differences between bisoprolol and carvedilol in patients with chronic heart failure and chronic obstructive pulmonary disease: a randomized trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) frequently coexists in patients with chronic heart failure (CHF) and is a key factor for beta blocker underprescription and underdosing. This study compared effects of bisoprolol and carvedilol in patients with both conditions.

METHODS

This was a randomized open-label study, of bisoprolol and carvedilol during initiation and uptitration to target or maximal tolerated dose. Pulmonary function testing, 12-lead electrocardiogram, and N-terminal pro brain natriuretic peptide were measured at baseline and follow-up.

RESULTS

We randomized 63 elderly patients (73 ± 9 years, 81% men, left ventricular ejection fraction 33 ± 7%) with mild to moderate CHF (54% New York Heart Assocation class II) and moderate to severe COPD (76% Global initiative for chronic Obstructive Lung Disease stage 2). Target dose was tolerated by 31 (49%) patients and 19 (30%) patients experienced adverse events during follow-up (19% bisoprolol, 42% carvedilol, p = 0.045). Study medication had to be withdrawn in 8 (13%) patients (bisoprolol: 2 due to hypotension, 1 due to bradycardia; carvedilol: 2 due to hypotension and 1 due to wheezing, dyspnoea, and oedema, respectively). Forced expiratory volume in 1(st) second significantly increased in bisoprolol (1561 ± 414 ml to 1698 ± 519 ml, p = 0.046) but not carvedilol (1704 ± 484 to 1734 ± 548, p = 0.44) group. Both agents reduced heart rate (bisoprolol: 75 ± 14 to 68 ± 10, p = 0.007; carvedilol 78 ± 14 to 72 ± 12, p = 0.016) and had no effect on N-terminal pro brain natriuretic peptide.

CONCLUSIONS

Beta blockers frequently caused adverse events, and thus 49% of patients could tolerate the target dose. Bisoprolol induced demonstrable improvement in pulmonary function and caused less adverse events.

Chronic heart failure: we are fighting the battle, but are we winning the war?

Heart failure represents an end-stage phenotype of a number of cardiovascular diseases and is generally associated with a poor prognosis. A number of organized battles fought over the last two to three decades have resulted in considerable advances in treatment including the use of drugs that interfere with neurohormonal activation and device-based therapies such as implantable cardioverter defibrillators and cardiac resynchronization therapy. Despite this, the prevalence of heart failure continues to rise related to both the aging population and better survival in patients with cardiovascular disease. Registries have identified treatment gaps and variation in the application of evidenced-based practice, including the use of echocardiography and prescribing of disease-modifying drugs. Quality initiatives often coupled with multidisciplinary, heart failure disease management promote self-care and minimize variation in the application of evidenced-based practice leading to better long-term clinical outcomes. However, to address the rising prevalence of heart failure and win the war, we must also turn our attention to disease prevention. A combined approach is required that includes public health measures applied at a population level and screening strategies to identify individuals at high risk of developing heart failure in the future.

The carvedilol's beta-blockade in heart failure and exercise training's sympathetic blockade in healthy athletes during the rest and peak effort

In recent years, beta-blocker therapy has become a primary pharmacologic intervention in patients with heart failure by blocking the sympathetic activity. To compare the exercise training's sympathetic blockade in healthy subjects (athletes) and the carvedilol's sympathetic blockade in sedentary heart failure patients by the evaluation of the heart rate dynamic during an exercise test. A total of 26 optimized and 49 nonoptimized heart failure patients in a stable condition (for, at least, 3 months), 15 healthy athletes and 17 sedentary healthy subjects were recruited to perform a cardiopulmonary exercise test. The heart rate dynamic (rest, reserve, peak and the peak heart rate in relation to the maximum predicted for age) was analyzed and compared between the four groups. The heart rate reserve was the same between optimized (48 +/- 15) and nonoptimized (49 +/- 18) heart failure patients (P < 0.0001). The athletes (188 +/- 9) showed a larger heart rate reserve compared to sedentary healthy subjects (92 +/- 10, P < 0.0001). Athletes and healthy sedentary reached the maximum age-predicted heart ratefor their age, but none of the heart failure patients did. The carvedilol's sympathetic blockade occurred during the rest and during the peak effort in the same proportion, but the exercise training's sympathetic blockade in healthy subjects occurred mainly in the rest.

Effects of B-Blockers on outcome of patients with Chagas' cardiomyopathy with chronic heart failure

BACKGROUND

A few studies have shown a beneficial effect of B-Blocker therapy on cardiac function and functional status in patients with chronic heart failure secondary to Chagas' cardiomyopathy.

METHODS

The medical charts of patients routinely followed from January, 2000 to January, 2007 were reviewed to collect clinical, standard laboratory tests, 12-lead electrocardiogram, chest X-Ray, and Doppler echochardiogram variables. A Cox proportional hazards model was used to establish independent predictors of all-cause mortality for patients with Chagas' cardiomyopathy with chronic heart failure.

RESULTS

A total of 231 consecutive patients were enrolled in the study. Median follow up was 19 (7, 46) months. Twenty (9%) patients underwent heart transplantation and 120 (52%) died during the investigation. Left ventricular systolic dimension (hazard ratio=1.04; 95% confidence interval=1.02 to 1.06; p<0.005) and need of inotropic support (hazard ratio=1.80; 95% confidence interval 1.2 to 2.60; p=0,03), were positively associated, whereas B-Blocker therapy (HR=0.34; 95% confidence interval 0.23 to 0.51; p<0.0005) was negatively associated with mortality. Mortality was significantly lower in patients taking in comparison to those not taking B-Blockers. Patients taking a mean daily dose of carvedilol>or=to 9.375mg had a marked decrease in mortality in comparison to those not on carvedilol therapy.

CONCLUSION

B-Blockers are effective, not detrimental, and may improve survival in Chagas' disease patients with chronic heart failure. A randomized trial is necessary to confirm these findings.

Current treatment of chronic heart failure in primary care; still room for improvement

RATIONAL AND AIMS: In recent years, guidelines for treatment of patients with chronic heart failure (CHF) have been updated. Insight in current pharmacological and non-pharmacological treatment of CHF in primary care, which was non-optimal in earlier studies, is limited. We aim to describe current pharmacological and non-pharmacological treatment of CHF in primary care.

METHODS

In this cross-sectional observational study, we included a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined medical record data with data from patient and doctor questionnaires.

RESULTS

Mean age of patients was 75.7 years (SD 10.2), 53% were male, and 73% of patients had mild heart failure (New York Heart Association class I or II). 76.5% of patients received diuretics. Angiotensin-converting enzyme inhibitors were prescribed in 40.6% and angiotensin-II receptor blockers in 20.7%; beta-blockers were prescribed to 54.6%, while 24.9% received spironolactone. Patients with more severe heart failure had a lower probability of being treated according to guideline recommendations. Relevant lifestyle advice was given to 40-60% of the patients, depending on the specific lifestyle advice.

CONCLUSIONS

Implementation of evidence-based pharmacotherapy for heart failure in primary care has improved since clinical guidelines have been updated; especially with respect to prescription of beta-blockers. However, there still seems ample room for improvement, as in the case for providing lifestyle advice.

Norepinephrine remains increased in the six-minute walking test after heart transplantation

OBJECTIVE

We sought to evaluate the neurohormonal activity in heart transplant recipients and compare it with that in heart failure patients and healthy subjects during rest and just after a 6-minute walking test.

INTRODUCTION

Despite the improvements in quality of life and survival provided by heart transplantation, the neurohormonal profile is poorly described.

METHODS

Twenty heart transplantation (18 men, 49+/-11 years and 8.5+/-3.3 years after transplantation), 11 heart failure (8 men, 43+/-10 years), and 7 healthy subjects (5 men 39+/-8 years) were included in this study. Blood samples were collected immediately before and during the last minute of the exercise.

RESULTS

During rest, patients' norepinephrine plasma level (659+/-225 pg/mL) was higher in heart transplant recipients (463+/-167 pg/mL) and healthy subjects (512+/-132), p<0.05. Heart transplant recipient's norepinephrine plasma level was not different than that of healthy subjects. Just after the 6-minute walking test, the heart transplant recipient's norepinephrine plasma level (1248+/-692 pg/mL) was not different from that of heart failure patients (1174+/-653 pg/mL). Both these groups had a higher level than healthy subjects had (545+/-95 pg/mL), p<0.05.

CONCLUSION

Neurohormonal activity remains increased after the 6-minute walking test after heart transplantation.

Clinical updates on carvedilol: a first choice beta-blocker in the treatment of cardiovascular diseases

IMPORTANCE OF THE FIELD

Carvedilol, a non-selective beta-blocker, has recently drawn attention because of its therapeutic benefits over other prescribed analogues for the treatment of cardiovascular diseases (CVDs).

AREAS COVERED IN THIS REVIEW

The present review attempts to present the clinical efficacy of carvedilol in comparison to other available beta-blockers. The literature search was carried out in three electronic databases (Unbound Medline, Pubmed and Sciencedirect) and internet search engines (Scirus and Google Scholar) without time constraints to ensure maximum literature coverage.

WHAT THE READER WILL GAIN

A relatively large number of comparative studies have revealed that carvedilol has advantage over traditional beta-blockers with respect to hemodynamic and metabolic effects, due to its unique non-selective alpha-/beta-adrenoceptor affinity. Such results indicate its safe and effective therapeutic application particularly in patients with complicated CVDs, even in pediatric and geriatric patients.

TAKE HOME MESSAGE

The therapeutic profile of carvedilol indicates its suitability for treatment of complicated CVDs than other non-selective beta-blockers. However, there is a limitation in terms of its dose due to its low bioavailability (approximately 25%). Therefore, there is still need for bioavailability enhancement and dose reduction to further improve the therapeutic efficacy of the drug.

Clinical trials update from the Heart Failure Society of America Meeting 2009: FAST, IMPROVE-HF, COACH galectin-3 substudy, HF-ACTION nuclear substudy, DAD-HF, and MARVEL-1

This article presents findings and a commentary on late-breaking trials presented during the meeting of the Heart Failure Society of America in September 2009. Unpublished reports should be considered as preliminary, since analyses may change in the final publication. The FAST trial showed somewhat better performance of intrathoracic impedance for prediction of deterioration in patients with heart failure (HF) when compared with daily weighing. The IMPROVE-HF study reported the benefits of education on the management of patients with systolic HF. Galectin-3 appeared a useful method for improving risk stratification of patients with chronic HF in a substudy of the COACH trial. A nuclear substudy of the HF-ACTION trial failed to demonstrate that resting myocardial perfusion imaging, a measure of myocardial scar and viability, was clinically useful. A small randomized controlled trial (DAD-HF) suggested that the use of low-dose dopamine in patients with acutely decompensated HF was associated with less deterioration in renal function and less hypokalaemia. The MARVEL-1 trial raises further concerns about the safety of myoblast transplantation in ischaemic HF.

The burden of chronic obstructive pulmonary disease in patients hospitalized with heart failure

OBJECTIVES

Like chronic heart failure, chronic obstructive pulmonary disease (COPD) is an enormous public health problem in industrialized countries. Our aim was to determine the prevalence and clinical impact of COPD among patients hospitalized for heart failure in a community hospital serving a population of 125,000 people.

METHODS

Between 2001 and 2003 a total of 638 patients (73 +/- 10 years, 48% men, 74% NYHA class III) were identified with a discharge diagnosis of heart failure. Medical charts were reviewed and vital status was obtained from a Central Population Registry.

RESULTS

COPD was diagnosed in 106 (17%) patients whose age was similar to those without COPD (73 +/- 9 vs. 73 +/- 11 years, P = 0.35). Patients with COPD were more often males (65% vs. 45%, P < 0.001). There were no differences in arterial hypertension, atrial fibrillation, diabetes mellitus and most laboratory markers except hemoglobin (141 +/- 20 vs. 132 +/- 20 g/l, P < 0.001) and uric acid (453 +/- 136 vs. 414 +/- 139 mmol/l, P = 0.013). At discharge, patients with COPD were less likely to receive beta-blockers (12% vs. 28%, odds ratio 0.35, 95% CI0.19-0.64). During follow-up, patients with COPD had higher mortality (73% vs. 60%, P = 0.016, hazard ratio 1.48, 95% CI 1.15-1.90). Kaplan-Meier (log-rank test, P = 0.002) and Cox proportional hazard analysis, adjusted for age, sex, hemoglobin, uric acid, and treatment with beta-blockers and furosemide (hazard ratio 1.38, 95% CI1.04-1.83, P = 0.024) demonstrated the prognostic importance of COPD.

CONCLUSIONS

COPD is frequent among hospitalized patients with heart failure. Beta-blockers are largely underused, which is probably a major reason for the higher mortality observed in patients with concomitant chronic heart failure and COPD.

Nitric oxide mechanisms of nebivolol

β-blockers are among the most widely used drugs in the prevention and treatment of cardiovascular disease, although they are associated with increased peripheral resistance. Third-generation β-blockers avoid this adverse effect by inducing vasodilation through different mechanisms. In particular, nebivolol, a highly selective blocker of β1-adrenergic receptors, is the only β-blocker known to induce vascular production of nitric oxide, the main endothelial vasodilator. The specific mechanism of nebivolol is particularly relevant in hypertension, where nitric oxide dysfunction occurs. Indeed, nebivolol is able to reverse endothelial dysfunction. Nebivolol induces nitric oxide production via activation of β3-adrenergic receptors, which can explain the good metabolic profile observed after treatment with this drug. Moreover, nebivolol can also stimulate the β3-adrenergic receptor-mediated production of nitric oxide in the heart, and this stimulation can result in a greater protection against heart failure. In conclusion, nebivolol has a unique profile among antihypertensive drugs, adding to a very high selectivity against β1 adrenergic receptors, and an agonist action on β3 receptors and nitric oxide (NO), which has led to clinically significant improvements in hypertensive patients.