Q J Med 2002; 95: 55-56
© 2002 Association of Physicians
Correspondence |
Can beta blockers be safely initiated at home in patients with heart failure?
Department of Cardiology, St. Mary's Hospital, Portsmouth
Department of Cardiology, St. Richards Hospital, Chichester
Sir,
Beta-blockers reduce mortality and morbidity in chronic heart failure.1,2 Concerns over syncope secondary to hypotension or bradycardia, and acute deterioration in heart failure symptoms on initiating such therapy, have lead to recommendations that first doses be given over several hours of medical supervision and monitoring, but evidence for the need for this practice is lacking.3 Whether beta blocker therapy can be safely introduced at home in patients with chronic heart failure is unknown, and is relevant to the development of community-based heart failure services.
We conducted a study at two district general hospitals in the South of England (St. Richard's Hospital, Chichester and St. Mary's Hospital, Portsmouth). Both operated heart failure clinics, and patients qualified for beta-blockers (bisoprolol) if they had stable grade II–IV heart failure and were already taking an angiotensin-converting-enzyme inhibitor and a diuretic. Patients with a heart rate <50 bpm or a blood pressure <90/50 mmHg were excluded. Patients were supervised by a nurse in hospital for 4 h following the first dose of bisoprolol (1.25 mg), as recommended in the drug manufacturer's guidelines.3 Most patients were seated for this time but were free to move around. Blood pressure and pulse were monitored and any adverse events were recorded; this information was stored with other clinical details on databases at each institution. We report the incidence of adverse events on 264 consecutive patients.
Table 1
shows the number of adverse events according to the severity of heart failure. There were no serious adverse events, no cases of symptomatic bradycardia or syncope and no patient became visibly more breathless at rest. The average fall in systolic blood pressure was 8 mmHg; 14 patients experienced falls >20 mmHg, but 13 of these experienced no symptoms. One patient with a dilated cardiomyopathy and severe (grade IV) heart failure experienced dizziness associated with a fall in systolic blood pressure from 122 mmHg to 79 mmHg. He required 6 h of bed rest before he was discharged home with the beta-blocker discontinued.
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Our results on 264 patients allow us to be reasonably certain (95% confident) that any adverse event on initiating beta-blocker therapy is unlikely to occur more frequently than in 1.4% of all patients with heart failure. For each 4-h stay per patient, a total of 894 patient-hours were supervised by a nurse in hospital to manage one minor adverse event that could with appropriate advice have been managed at home.
Our results suggest that for patients with mild-to-moderate heart failure, home initiation of beta-blockers is reasonable. Such patients should ideally start therapy with another adult in attendance; this person and the patient should be given advice on how to proceed should adverse events occur, in the knowledge that any that do occur are likely to be little more than minor.
The subjects in our study represented the spectrum of heart failure patients in the community, and included a greater proportion of women (25%) and elderly people (mean age 67, range 19–91) than participated in randomized trials.1,2 Our group also included patients who would have been excluded from these trials on account of electrocardiographic conduction abnormalities (present in about one third of our population), demonstrating the safety of this approach even in this subgroup. Patients with grade IV heart failure were underrepresented in our population but with one adverse event in five cases, it seems reasonable to continue to initiate beta-blockers in such patients in hospital.
Compliance with guidelines on heart failure management is poor, with 5% of eligible patients receiving beta-blockers in the UK.4,5 The obstacle of initiating beta-blockers under medical supervision may be limiting the uptake of this effective treatment. Recommending home initiation for most patients with mild-to-moderate symptoms should increase opportunities for general practices to develop local heart failure services and facilitate the implementation of national guidelines.
We gratefully acknowledge the support of the British Heart Foundation, and thank Martin Drew for technical support and Malcolm Law for his helpful advice.
References
1. CIBIS-II Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS II): a randomized trial. Lancet1999; 353:9–13.[Web of Science][Medline]
2. MERIT-HF Group. Effect of metoprolol on CR/XL in chronic heart failure: Metoprolol CR/XL Randomized intervention trial in Congestive Heart Failure(MERIT-HF). Lancet1999; 353:2001–7.[Web of Science][Medline]
3. Formulary Information 2000; Suppl. ZZ19040:3. Merck Cardiovascular.
4.
Remme WJ, Cleland JGF, Dargie H, Erdmann E, Ferrari R, Kjekhus J, et al. The treatment of heart failure. Eur Heart J1997; 18:736–53.
5. Wise J. New heart failure management programme set to take shared care nationwide. Br J Cardiol2001; 8:414–16.
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