When should carvedilol (beta-blocker) be held?

When to Hold Carvedilol

Hold carvedilol immediately in patients with cardiogenic shock or severe hypoperfusion, and consider temporary discontinuation during acute decompensation with dose reduction as needed, but attempt reinstitution before hospital discharge. 1

Absolute Indications to Hold Carvedilol

Cardiogenic Shock and Severe Hypoperfusion

• Temporarily discontinue carvedilol in shocked or severely hypoperfused patients 1
• Reinstitution should be attempted before hospital discharge once clinical stability is restored 1

Severe Bradycardia

• Hold if pulse rate drops below 55 beats per minute and reduce dosage 2
• Avoid initiation in patients with significant sinus bradycardia (heart rate <50 beats/min) 3
• Do not use in patients with second- or third-degree heart block or sick sinus syndrome without a permanent pacemaker 1

Severe Hypotension

• Hold if systolic blood pressure falls below 90 mmHg 3
• Monitor closely during initiation, as postural hypotension occurred in 20.2% of post-MI patients receiving carvedilol 2

Relative Indications to Hold or Reduce Dose

Acute Decompensation of Heart Failure

• Continuation during decompensation has been shown safe in RCTs, though dose reduction may be necessary 1
• If worsening heart failure or fluid retention occurs during up-titration, increase diuretics and do not advance carvedilol dose until clinical stability resumes 2
• Occasionally temporary discontinuation is necessary, but this does not preclude subsequent successful titration 2

Acute Intercurrent Conditions in Cirrhosis Patients

• In patients with cirrhosis and varices, discontinue carvedilol during acute bleeding, sepsis, spontaneous bacterial peritonitis, or acute kidney injury 1
• Hold if progressive hypotension develops (systolic BP <90 mmHg) 1
• After recovery from these acute conditions, reinstatement can be attempted 1

Severe or Refractory Ascites (Cirrhosis)

• Consider dose reduction or temporary discontinuation in patients with refractory ascites and systolic blood pressure <90 mmHg, serum creatinine >1.5 mg/dl, or hyponatremia <130 mmol/L 1
• High doses should be avoided in this population 1

Bronchospasm

• If any evidence of bronchospasm is observed during up-titration, lower the dose 2
• Use with caution in patients with chronic obstructive pulmonary disease, though COPD is not an absolute contraindication 1
• Asthma is an absolute contraindication 1

Critical Warnings About Discontinuation

Never Abruptly Discontinue

• Abrupt discontinuation can lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias in patients with coronary artery disease 2
• When planned discontinuation is necessary, taper over 1 to 2 weeks whenever possible 2
• If angina worsens or acute coronary insufficiency develops during tapering, promptly reinstitute carvedilol 2
• Even in patients treated only for hypertension or heart failure, avoid abrupt discontinuation as coronary artery disease may be unrecognized 2

Monitoring Parameters to Guide Holding Decisions

• Check heart rate, blood pressure, and clinical status before each dose increase 3
• Monitor for signs of fluid retention, rales, and bronchospasm during titration 3
• Aim for resting heart rate of 50-60 beats per minute unless limited by side effects 3
• During initiation, caution patients to avoid driving or hazardous tasks where injury could result if syncope occurs 2

Common Pitfall

The most critical error is abruptly stopping carvedilol without tapering, particularly in patients with known or suspected coronary artery disease, as this can precipitate life-threatening cardiovascular events 2. Even during acute illness requiring temporary discontinuation, plan for reinstitution as soon as clinically appropriate 1.