Use of carvedilol in chronic heart failure: challenges in therapeutic management

In controlled trials, long-term treatment of patients with chronic heart failure with beta-blockers improves symptoms, slows progression of disease, and reduces morbidity and mortality rates. However, in some patients the introduction of therapy can be associated with a period of clinical instability, including risks of fluid retention, hypotension, and bradycardia. Appropriate patient selection and optimization of background therapy can minimize the risk during the introduction of therapy. With vigilance for early signs of clinical deterioration and appropriate adjustment of background medications, the care of most patients exhibiting clinical instability can be successfully managed so the patient is able to continue with the long-term therapy, a prerequisite to realizing beneficial effects. With the initiation of carvedilol, any evidence of fluid retention warrants a prompt increase in the diuretic dosage, and in more pronounced cases the carvedilol dose may need to be reduced or interrupted. In contrast, symptoms of hypotension (most commonly dizziness) generally resolve without intervention, although persistent problems may necessitate adjusting the timing of dose administration or perhaps temporarily reducing the dose of vasodilators or diuretics (the latter with care to avoid fluid retention). Bradycardia should be managed as standard practice would indicate. During long-term treatment, adjustments in beta-blocker dosage may be required in the event of an exacerbation of heart failure. Dosages should be adjusted as would be the case with other heart-failure medications, based on the severity of the clinical decompensation, but with care to minimize abrupt changes unless mandated by the patient's condition and to avoid precipitating ischemia or further deterioration. The occurrence of effects such as these does not necessarily indicate that a patient cannot respond favorably to long-term beta-blockade, but all require understanding, vigilance, and the availability of medical personnel, especially during the introduction of this therapy.