Table 3

Guidance on when, where and how to use BBs in heart failure and guidance on ‘troubleshooting’ common issues

When to useACE inhibitors are the first-line treatment in all patients with systolic heart failure alongside BBs.
When not to useAsthma, marked bradycardia, pheochromocytoma.
CautionsCurrent or recent exacerbation of heart failure, severe heart failure (NYHA class III–IV). Bradycardia, hypotension (<90 mm Hg systolic), signs of current volume overload. Psoriasis, hypoglycaemia, concurrent use of rate-limiting calcium channel blockers.
How to use‘Start low and go slow’. Double the dose every 2 weeks at the fastest. Monitor blood pressure and blood biochemistry 1–2 weeks after initiation and final dose titration. Monitor heart rate and blood pressure and watch for signs of decompensating heart failure.
CounsellingExplain expected benefits and possible side effects, advise on monitoring and drugs to avoid. Explain intended benefits may not occur for months and that stopping their BB should be done only with medical supervision. Liaise with community heart failure nurse-led services.
TroubleshootingIf increasing congestion increase dose of diuretic and/or halve dose of BB if increasing the diuretic does not work. In fatigue (and/or bradycardia) halve dose of BB and review patient in 1–2 weeks. If serious deterioration, stop the BB and seek specialist advice.
Bradycardia
If heart rate <50 bpm and worsening symptoms halve the dose of the BB or, if there is a severe deterioration, stop the BB (rarely necessary) and review need for other drugs. Arrange an ECG to exclude heart block and seek specialist advice.
Hypotension
Asymptomatic hypotension does not usually require any changes but if symptomatic hypotension occurs, consider stopping/reducing other hypotensive agents (diuretics, calcium channel blockers). If these measures do not solve problem, seek specialist advice.
  • Adapted from McMurray et al and the British National Formulary.17 ,18

  • ACE, angiotensin-converting enzyme; BB, β-blocker; NYHA, New York Heart Association.