What medication would you start a patient on initially if suspected of having Heart Failure (HF), who is currently taking Hydrochlorothiazide (HCTZ) and Lisinopril, an Angiotensin-Converting Enzyme (ACE) inhibitor?

Beta-Blocker Addition for Suspected Heart Failure in a Patient on Hydrochlorothiazide and Lisinopril

For a patient with suspected heart failure who is already taking hydrochlorothiazide and lisinopril, you should add one of the three evidence-based beta-blockers (bisoprolol, carvedilol, or metoprolol succinate) as the next medication. 1

First-Line Therapy for Heart Failure

• ACE inhibitors (like lisinopril) and beta-blockers constitute the first-line therapy for patients with heart failure due to left ventricular systolic dysfunction 1
• The patient is already on an ACE inhibitor (lisinopril), so adding a beta-blocker is the appropriate next step in optimizing heart failure therapy 1
• Beta-blockers have been conclusively shown to increase survival, reduce hospitalizations, and improve NYHA class and quality of life when added to standard therapy (diuretics and ACE inhibitors) 1

Beta-Blocker Selection

Only three beta-blockers have demonstrated mortality reduction in heart failure and should be considered:

• Bisoprolol: Starting dose 1.25 mg once daily, target dose 10 mg once daily 1
• Carvedilol: Starting dose 3.125 mg twice daily, target dose 25-50 mg twice daily 1
• Metoprolol succinate (CR/XL): Starting dose 12.5-25 mg once daily, target dose 200 mg once daily 1

Implementation Strategy

• Start with a very low dose (one-tenth to one-twentieth of doses used for angina or hypertension) 2
• Titrate slowly, doubling the dose at not less than 2-week intervals 1
• Aim for the target dose used in clinical trials or the highest tolerated dose 1
• Monitor heart rate, blood pressure, clinical status, and signs of congestion during titration 1

Precautions and Monitoring

• Ensure the patient is stable before initiating beta-blocker therapy (not during acute decompensation) 1
• Monitor for potential worsening of heart failure symptoms during initiation phase (occurs in approximately 20-30% of cases) 1
• If congestion worsens, first increase the diuretic dose before considering beta-blocker dose reduction 1
• Check blood chemistry 12 weeks after initiation and 12 weeks after final dose titration 1

Special Considerations

• The benefits of beta-blockers cannot be assumed to be a class effect in heart failure; use only the three evidence-based agents mentioned above 1
• Even a low dose of beta-blocker is better than no beta-blocker if target doses cannot be achieved 1
• Temporary symptomatic deterioration may occur during initiation/up-titration phase but usually resolves with continued therapy 1
• Advise patients that symptomatic improvement may develop slowly (3-6 months or longer) 1

Common Pitfalls to Avoid

• Avoid starting beta-blockers during acute decompensation of heart failure 1
• Do not initiate beta-blockers in patients with signs of fluid overload; optimize diuretic therapy first 1
• Do not abruptly discontinue beta-blocker therapy due to risk of rebound effects 1
• Avoid non-evidence-based beta-blockers for heart failure treatment 1
• Do not use calcium channel blockers as routine treatment for heart failure as they are not indicated and may be harmful 1

Future Considerations

• If the patient remains symptomatic despite optimal therapy with an ACE inhibitor and beta-blocker, consider adding an aldosterone antagonist or transitioning to sacubitril/valsartan 1, 3
• Sacubitril/valsartan is indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure, but requires a 36-hour washout period when switching from an ACE inhibitor 3