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(Excluding bdf..% bdl..% bdm..% )
- 14LL. H/O: betablocker allergy
- TJC6. Adverse reaction to betablockers
- TJC61 Adverse reaction to acebutolol
- TJC62 Adverse reaction to atenolol
- TJC63 Adverse reaction to labetalol
- TJC64 Adverse reaction to metoprolol
- TJC65 Adverse reaction to nadolol
- TJC66 Adverse reaction to oxprenolol
- TJC67 Adverse reaction to sotalol
- TJC68 Adverse reaction to timolol
- TJC6z Adverse reaction to betablockers NOS
- U60B7 [X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not elsewhere classified
- ZV14C [V]Personal history of betablocker allergy
U60B9 [X]Adverse reaction to bisoprolol
U60BA [X]Adverse reaction to carvedilol
U60BB [X]Adverse reaction to nebivolol
ZVu6i [X]Personal history of allergy to bisoprolol
ZVu6o [X]Personal history of allergy to carvedilol
ZVu6q [X]Personal history of allergy to nebivolol
TJC00 Adverse reaction to practolol (v26)
TJC02 Adverse reaction to propranolol (v26)
- 8I26. Beta blocker contraindicated
- 8I36. Beta blocker therapy refused
- 8I62. Beta blocker not indicated
- 8I73. Beta blocker not tolerated
8I2g. Bisoprolol contraindicated
8I2h. Carvedilol contraindicated
8I2i. Nebivolol contraindicated
8I6i. Bisoprolol not indicated
8I6j. Carvedilol not indicated
8I6k. Nebivolol not indicated
8I7K. Bisoprolol not tolerated
8I7L. Carvedilol not tolerated
8I7M. Nebivolol not tolerated
8IAS. Bisoprolol therapy refused
8IAT. Carvedilol therapy refused
8IAV. Nebivolol therapy refused
The evidence base for treating heart failure due to LVSD with beta-blockers6, 7 is at least as strong as the evidence base guiding the HF 3 indicator on ACE inhibitors (Level Ia), with a 34% reduction in major endpoints of beta-blockers on top of ACE inhibitors compared to placebo, and is a standard recommendation in all heart failure guidelines including NICE. The belief that beta-blockers are contra-indicated in heart failure was disproved, at least for the licensed beta-blockers, in the late 1990s and in some countries (especially Scandinavia) beta-blockers have never been contraindicated in heart failure. Furthermore, there are no data to suggest excess risk in the elderly (SENIORS with nebivolol only randomised people over 75 with significant benefits and no safety signal) and there are no contra-indication for use in people with chronic obstructive pulmonary disease COPD.
However, despite the evidence above, initiating beta-blockers in HF, or switching from one not licensed for HF, is more difficult because of the need to titrate from low doses and small increments over repeated visits. Patients also often suffer a temporary deterioration in symptoms with beta-blocker initiation which needs monitoring.
The British National Formulary (BNF) states that “the beta-blockers bisoprolol and carvedilol are of value in any grade of stable HF and LVSD; nebivolol is licensed for stable mild to moderate HF in patients aged over 70, beta-blocker treatment should be initiated at a very low dose and titrated very slowly over a period of weeks or months by those experienced in the management of HF. Symptoms may deteriorate initially, calling for adjustment of concomitant therapy”
NICE clinical guideline CG108 and SIGN clinical guideline 95 recommend that beta-blockers licensed for HF are used as first-line therapy in all patients with HF due to LVSD. CG108 recommends that beta-blockers are used in patients with defined co-morbidities such as older adults and those with peripheral vascular disease (PVD), erectile dysfunction (ED), DM, interstitial pulmonary disease and COPD without reversibility. The only co-morbidities with a clear contra-indication to beta-blocker use are those with asthma and reversible airways obstruction (these groups were excluded from clinical trials).
Contractors are advised that patients already prescribed an unlicensed beta-blocker prior to diagnosis of HF due to LVSD do not have their drug therapy changed to meet the criteria of this indicator. Those patients already prescribed an unlicensed beta-blocker will be excluded.
NICE CG108. Chronic HF: management of chronic HF in adults in primary and secondary
NICE quality standard. Chronic HF. 2011.
SIGN clinical guideline 95 (2007). Management of chronic heart failure.
See indicator wording for requirement criteria.
Patients already prescribed a beta-blocker unlicensed for heart failure will be excluded from this indicator.
Prepared By Jean Keenan