Carvedilol titration in patients with congestive heart failure receiving inotropic therapy.

BACKGROUND

Carvedilol has been shown to improve morbidity and mortality in patients with congestive heart failure (CHF). There are limited data of carvedilol use in patients on inotrope therapy. We present our experience with carvedilol titration in New York Heart Association (NYHA) class IIIb/IV patients stabilized on milrinone therapy, as a nonrandomized study with a parallel control group of patients never on inotropes. These patients achieved volume control and stabilization of their symptoms during the course of milrinone therapy.

METHODS AND RESULTS

Seventeen patients in class IIIb/IV CHF (group 1) on intermittent intravenous milrinone therapy and 15 patients in class II/IIIa compensated CHF (group 2) on standard triple heart failure therapy were titrated on carvedilol. Success and adverse events during titration were compared between the 2 groups. Fifteen (88%) patients in group 1 and 14 (93%) patients in group 2 were successfully titrated on carvedilol over 8.1 +/- 1.8 weeks and 6.7 +/- 2.8 weeks, respectively. The target dose of carvedilol (25 or 50 mg twice daily) was achieved in 13 (87%) patients (group 1) and 14 (93%) patients (group 2). Seven (47%) patients in group 1 and 4 (28%) patients in group 2 had adverse events during carvedilol titration. Eight (53%) patients in group 1 were weaned off milrinone over a period of 8.4 weeks after carvedilol titration, whereas the rest of the patients had reduction in the frequency of infusion. Ten (63%) patients in group 1 improved by one or more functional classes.

CONCLUSIONS

Patients in NYHA class IIIb/IV who are treated with inotropic therapy can be titrated on carvedilol after reaching a stable state while on milrinone and standard oral drugs. Most of these patients can be successfully weaned off of milrinone or have decreased frequency of infusions and demonstrate improved functional status. Prospective randomized trials are required to evaluate these observations made in a limited number of patients in class IIIb and IV CHF because the combination of milrinone and beta-blockers has never been adequately evaluated.