Should a patient with hypertension (HTN) and a history of heart failure be switched from metoprolol ER (metoprolol) to Coreg (carvedilol) due to poor blood pressure control?

Switching from Metoprolol ER to Carvedilol for Hypertension Control in Heart Failure

Yes, you should switch your patient with hypertension and heart failure from metoprolol ER to carvedilol due to poor blood pressure control. Carvedilol offers superior blood pressure control in heart failure patients due to its additional alpha-blocking properties, while maintaining the beta-blocker benefits for heart failure management 1, 2.

Rationale for Switching to Carvedilol

• Carvedilol has combined α1, β1, and β2-blocking properties that make it more effective in reducing blood pressure than metoprolol, which only has β1-blocking properties 2, 3
• The COMET trial demonstrated a 17% greater mortality reduction with carvedilol compared to metoprolol tartrate in heart failure patients 2, 4
• Carvedilol is specifically recommended by guidelines as one of the four beta-blockers (along with metoprolol succinate, bisoprolol, and nebivolol) proven to reduce mortality in heart failure patients 2
• For patients with refractory hypertension and heart failure, carvedilol may be the beta-blocker of choice due to its vasodilatory effects 2

Benefits of Carvedilol in Heart Failure with Hypertension

• Carvedilol reduces afterload through vasodilation, which offsets the negative inotropic effect that would normally result from beta-blockade 3
• The COPERNICUS trial showed carvedilol reduced mortality risk at 12 months by 38% and the risk of death or hospitalization for heart failure by 31% in patients with severe heart failure symptoms 1
• Carvedilol has a more favorable metabolic profile with less negative impact on glycemic control compared to some other beta-blockers 1, 5
• Carvedilol has antioxidant properties that may provide additional cardioprotection beyond its hemodynamic effects 3, 6

Implementation Strategy

• Start with a low dose of carvedilol (3.125 mg twice daily) and titrate gradually to avoid hypotension 7
• Administer with food to decrease the likelihood of syncope or excessive hypotension 7
• Target dose is 25 mg twice daily, as higher doses have shown greater left ventricular functional and clinical benefits in the MOCHA trial 2, 1
• Monitor for bradycardia and hypotension during initiation and titration 7

Management of Potential Side Effects

• If hypotension occurs during up-titration, increase diuretics if there are signs of fluid retention before reducing the carvedilol dose 7
• If hypotension persists without congestion, consider reducing doses of other vasodilators (ACE inhibitors, nitrates) before reducing carvedilol 1
• Never discontinue carvedilol abruptly as this may lead to severe exacerbation of angina, myocardial infarction, or ventricular arrhythmias 7
• If intolerable side effects persist despite management strategies, consider switching to bisoprolol, which has been shown to ameliorate dizziness and hypotension in some heart failure patients previously on carvedilol 8

Comprehensive Heart Failure Management

• Continue guideline-directed medical therapy including ACE inhibitors (or ARBs), beta-blockers, and aldosterone receptor antagonists 2
• Use thiazide or thiazide-type diuretics for BP control and to reverse volume overload; in severe heart failure, loop diuretics may be necessary 2
• Consider adding hydralazine/isosorbide dinitrate to the regimen, especially in African American patients with NYHA class III or IV heart failure 2
• Target blood pressure is <130/80 mmHg, but consider lowering further to <120/80 mmHg if tolerated 2

By switching from metoprolol ER to carvedilol, you can improve blood pressure control while maintaining or enhancing the mortality benefit of beta-blockade in your patient with hypertension and heart failure.