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Heart failure in a district general hospital: are target doses of beta-blockers realistic?
P A Mehta1, S McDonagh, P A Poole-Wilson
1National Heart & Lung Institute, Imperial College, London , UK. pmehta7@hotmail.com
Insights
Carvedilol therapy for heart failure shows a high first-dose failure rate and poor tolerance in general hospitals. Achieving a target dose may not be clinically useful, suggesting a need for practical treatment guidelines.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Carvedilol therapy is known to reduce mortality in chronic heart failure patients.
- Multi-centre studies indicate low first-dose failure rates and good tolerability.
- Limited data exists on carvedilol eligibility and tolerance in district general hospital settings.
Purpose of the Study:
- To assess the eligibility and tolerance of heart failure patients to carvedilol in a general hospital.
- To evaluate carvedilol's effectiveness and patient response within a real-world clinical setting.
Main Methods:
- Prospective clinical audit of 100 heart failure patients.
- Assessment of eligibility criteria, first-dose failure rate, and target dose achievement.
- Evaluation of reasons for intolerance, hemodynamic changes (heart rate, blood pressure), and resource utilization.
Main Results:
- 62% of patients met eligibility criteria for carvedilol initiation.
- An 11.5% first-dose failure rate was observed, with only 6.6% achieving the target dose.
- Significant reductions in heart rate (15 bpm) and systolic blood pressure (17 mmHg) were noted.
Conclusions:
- Eligible patients in general settings exhibit high first-dose failure and poor tolerance to higher carvedilol doses.
- The clinical utility of achieving a specific 'target dose' is questionable.
- Heart failure treatment guidelines should incorporate practical considerations for general hospital implementation.
Background:
Carvedilol therapy reduces mortality in patients with chronic heart failure. Multi-centre studies suggest a low first dose failure rate and high levels of tolerability to carvedilol. Little is known, however, concerning the eligibility and tolerance to treatment with carvedilol within a district general hospital setting.
Aim:
To evaluate the eligibility and tolerance of patients with heart failure to carvedilol within a district general hospital.
Design:
Prospective clinical audit analysis.
Methods:
We assessed 100 heart failure patients eligibility to commence carvedilol therapy. In those who satisfied clinical criteria, we evaluated first dose failure rate, target dose achievement, reasons for intolerance, heart rate and blood pressure reduction and resource requirements over a six-month period.
Results:
Of 100 patients, 16% had contra-indications to commence carvedilol and 22% were receiving a beta-blocker as part of their existing heart failure therapy. Although 62% satisfied eligibility criteria, 1% refused therapy, thus 61% were initiated on carvedilol. The first dose failure rate was 11.5% and 6.6% of patients achieved 'target dose'. Mean heart rate and systolic blood pressure reductions were 15 (SE 1.2)bpm and 17 (SE 1.7) mmHg, respectively. Resource requirements included 155 hours of work-time for a trained heart failure specialist nurse and doctor.
Conclusions:
In the general setting, eligible patients appear to display a high first dose failure rate, poor tolerance to higher doses and achievement of a 'target dose' of carvedilol. Responses to adrenergic blockade were similar to previously published data, irrespective of the final tolerated dose, suggesting that the concept of achieving a 'target dose' may not be clinically useful. Guidelines and treatment protocols for heart failure should reflect not only what is considered gold standard, but also what is practical in general hospitals.
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