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bdf..%
bdl..%
bdm..%
bd...%
(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 (v16)
U60BA [X]Adverse reaction to carvedilol (v16)
U60BB [X]Adverse reaction to nebivolol (v16)
ZVu6i [X]Personal history of allergy to bisoprolol (v16)
ZVu6o [X]Personal history of allergy to carvedilol (v16)
ZVu6q [X]Personal history of allergy to nebivolol (v16)
- 8I26. Beta blocker contraindicated
- 8I36. Beta blocker therapy refused
- 8I62. Beta blocker not indicated
- 8I73. Beta blocker not tolerated
8I2g. Bisoprolol contraindicated (v16)
8I2h. Carvedilol contraindicated (v16)
8I2i. Nebivolol contraindicated (v16)
8I6i. Bisoprolol not indicated (v16)
8I6j. Carvedilol not indicated (v16)
8I6k. Nebivolol not indicated (v16)
8I7K. Bisoprolol not tolerated (v16)
8I7L. Carvedilol not tolerated (v16)
8I7M. Nebivolol not tolerated (v16)
8IAS. Bisoprolol therapy refused (v16)
8IAT. Carvedilol therapy refused (v16)
8IAV. Nebivolol therapy refused (v16)
The evidence base for treating heart failure due to LVD 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 COPD.
However, this strategy is more difficult in clinical practice than initiating ACE (more contra-indications, less tolerated, with a need for slower but more dose titration steps. Furthermore, there are negative trials of beta-blockers in heart failure8 and concerns over the effectiveness of atenolol in reducing vascular risk generally. Therefore the beta blocker used should be one licensed for heart failure, which is also in line with NICE recommendations. The only such agents in the UK are carvedilol, bisoprolol and nebivolol.
Practices should be aware that patients already prescribed a beta-blocker prior to diagnosis of HF due to LVD should not have their drug therapy changed to meet the criteria of this indicator. Those patients already prescribed a beta-blocker will be excluded from the achievement calculator.
However, despite the evidence above, initiating beta-blockers in heart failure, or switching from one not licensed for heart failure, 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 states that ‘beta-blockers bisoprolol and carvedilol are of value in any grade of stable heart failure and left-ventricular systolic dysfunction; nebivolol is licensed for stable mild to moderate heart failure. Beta-blocker treatment should be started by those experienced in the management of heart failure, at a very low dose and titrated very slowly over a period of weeks or months. Symptoms may deteriorate initially, calling for adjustment of concomitant therapy’
The practice reports the percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker, who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers.
Prepared By Jean Keenan