What beta blockers are approved for heart failure?

What beta blockers are approved for heart failure?

There are two beta blockers approved for heart failure in the United States.

The first is metoprolol succinate (also called Toprol XL, Toprol, metoprolol ER or metoprolol ER succinate). This long-acting formulation should not be confused with short-acting metoprolol (metoprolol, metoprolol tartrate or Lopressor) which is NOT an approved drug for heart failure.

The second beta blocker approved for the treatment of heart failure is carvedilol (also called Coreg or Coreg CR).

Drugs that are NOT approved for heart failure include atenolol and Bystolic. These are approved to treat hypertension.

NOT APPROVED: metoprolol tartrate, Lopressor, atenolol, Bystolic

APPROVED: metoprolol succinate, Toprol XL, Toprol, metoprolol ER, metoprolol ER succinate, carvedilol, Coreg, Coreg CR


Keeping heart failure under control.

Three components of treating heart failure


There are three components to keeping heart failure under control:

–          Daily weights
–          Diuretics
–          Fluid restriction/salt restriction

Daily weights are critical for heart failure patients.

Weights should be done the first thing every morning on the same reliable home scale before eating or drinking anything generic. Establish a DRY WEIGHT with your physician.

Think of ALL WEIGHT GAIN as an INCREASE IN FLUID and not as getting fatter.

A weight gain of 2 pounds is significant. If you are taking diuretics on an as needed basis, a weight gain of two pounds or more means it is time to take your diuretic (water pill). Diuretics include Lasix, furosemide, Torsemide and metolazone.

If your weight continues to go up the next day, it would be appropriate to call your cardiologist. There is a point that you will no longer respond to oral medications as fluid accumulates in the body. Getting to this point is very serious and generally results in prolonged hospitalization.

As an example:

Let’s say a patient has established a dry weight of 170 pounds.

Day 1 – 169 lbs

Day 2 – 170 lbs

Day 3 – 172 lbs (take diuretic, improve fluid and salt restriction)

Day 4 – 170 lbs

Day 5 – 173 lbs (take diuretic)

Day 6 – 177 lbs (call Cardiologist first thing in the morning to adjust medications)

(Please note that some patients require daily diuretics and cannot take diuretics on an “as needed” basis.)

Fluid restriction is critical in the management of heart failure.

Generally, fluid intake should be limited to 2 liters of fluid a day or less. This includes all fluid intake, not just water. A good way to visualize the amount of daily fluid is to think of a two liter coke bottle. You can even buy a two liter coke and pour it into several cups or glasses that you might drink from on a daily basis. This will give you an idea of how much you can take on a daily basis.

Salt restriction is also critical. Do not add salt to food OR eat salty foods. One common mistake is eating soup. Soup (even low salt soup) is invariably high is salt and should be avoided. Some heart failure patients are so sensitive to sodium that a single salty meal can put them in the hospital.

The American Heart Association publishes several cookbooks which are a good resource to understand a low salt diet.


Should I Use Aspirin?

Aspirin acts on the platelets which are the blood clotting cells of the body. It makes them less “sticky” – less likely to form a blood clot.

If a cholesterol plaque inside a blood vessel ruptures, the body’s natural reaction is to form a clot in that area. This can lead to heart attacks (a total blockage of blood flow down a coronary artery) or stroke.

The U.S. Preventive Services Task Force (USPSTF) recommends men with no history of heart disease or stroke who are 45 to 79 years old use aspirin to prevent a heart attack.

It is further recommended that women with no history of heart disease or stroke who are 55 to 79 years old use aspirin to prevent an ischemic stroke.

As with all medications, aspirin should only be used when the benefits outweighs the risk. With aspirin the risks include serious bleeding including GI blood loss from an ulcer or from other parts of the GI tract. The other type of serious bleeding would be a bleeding type of stroke.. Please note the difference between a bleeding stroke and an ischemic stroke where the blood supply is cut off.


For almost everyone, the recommended dose is 81 mg a day. Almost all aspirin sold is safety coated or enteric coated to protect the stomach and this is probably the best type to take. If someone is hesitant to take it but should be on it, I encourage them to try it every other day or every third day until they feel comfortable taking it daily.

Aspirin has some effect on the platelets for up to 10 days so a little goes a long way.

Please note that this information is people who have never had a cardiovascular event.


Angiogram vs. Angioplasty (and stents)

An angiogram of the heart is a direct visualization of the coronary arteries and is the gold standard test to diagnose blockages in the arteries.

During an angiogram a light anesthesia is used to provide relaxation and a numbing medicine is administered in the groin over the femoral artery. A special IV (or sheath) is then placed in the artery. Through this IV a catheter is advanced to the heart and the coronary arteries are engaged. X-ray contrast is injected into the arteries and pictures are taken.

If a significant blockage is found (60-70% or greater) and this can be safely fixed, then an angioplasty will be done. A balloon is advanced to the site of the blockage and expanded to push the blockage to the sides of the artery. When the balloon is removed, blood can get through more easily. Most of the time a stent is also placed. A stent is a wire mesh tube that helps keep the artery open. Before stents were developed, about 2/3 of blockages came back. With bare metal stents only 1/3 of the blockages come back. With new drug eluting stents, less than 10% of the blockages come back.


Results of a cardiac catheterization

There are several results that are possible after undergoing cardiac catheterization (angiogram of the blood vessels of the heart).

The best result is that there are no critical blockages detected by the test. The chest pain and/or abnormal test results are not related to significant blockages in the arteries supplying blood to the heart. One of the most serious causes of the clinical findings has been ruled out with essentially 100% certainty. It would be like a cancer doctor telling you the good news that you do not have cancer.

The second result is that there is a significant blockage that was fixed with balloon angioplasty and stent placement. This allows you to go home the next day in most cases and avoid surgery. The procedure is usually done immediately after the angiogram by the interventional cardiologist.

Sometimes more than one blockage can be fixed during the same procedure, but generally the “culprit” lesion is intervened on and other less critical lesions are left for a different time. This is because of limits to the amount of contrast you can receive (which is harmful to the kidneys) and the amount of radiation you can get in one procedure.

The third result is that you have blockages that are not amenable to balloon angioplasty/stent placement. The blockages can be in areas that are too risky to fix or in a vessel that is too small. They may also be in non-critical areas and the risks outweigh the benefits. Additionally, an artery that is chronically 100% blocked cannot be opened without some increased risk to the patient.

The last result is that you have blockages that can only be fixed with bypass surgery. Generally (although not always) this is not an emergency. You recover normally from your angiogram and the cardiologist and cardiovascular surgeon will discuss with you the merits of performing bypass surgery versus continuing medical therapy.

There may be variations of the above outcomes, but these represent the most common findings/outcomes after an angiogram is done.


An introduction to chest pain

“Chest pain” is a general term used in the medical profession to describe ANY SYMPTOM IN THE CHEST. It may be a sign that the heart is not getting enough blood and should be evaluated in a timely manner. Pain in the chest may be described as a tightness, burning, squeezing or sharp pain. It is important to remember that every person is unique and symptoms may not necessarily come out of a textbook.

The location of chest pain is not necessarily critical in determining how serious it is. A heart attack or angina can present with right sided chest pain even though the heart is located primarily in the center and left part of the chest. The nerves inside the body (unlike the nerves on our skin) are very vague and may not exactly correlate with the location of the problem.

Pain may radiate to the back or shoulder(s) or it may go to the jaw. Cardiac chest pain may be associated more with lower jaw pain than both the upper and lower jaw hurting, but this is not a 100% rule.

In fact, there is nothing I can write about chest pain (coming from the heart not getting enough blood) that is always 100% true. Decreased blood flow to the heart may not be associated with ANY symptoms in the chest. A person can present with ONLY nausea, shortness of breath or feeling sweaty. One large retrospective study (based mostly on ECGs) suggests that up to 50% of first heart attacks were silent.

If a person has chest pain in a tiny point in the chest, it may be less likely to be coming from the heart. If the chest pain in reproducible by pushing on the chest, it is much less likely to be cardiac in nature. Whether the chest pain hurts worst with deep breathing is probably not helpful.  Again, it should be stressed that NO RULE ABOUT CHEST PAIN IS ALWAYS %100 TRUE.

When a patient presents with chest pain, the most common concern is whether there is decreased blood flow to the heart. In other words, is there a new critical blockage that is constricting blood flow to the heart. A significant blockage may present with symptoms that occur with exertion and go away at rest. During exertion the heart needs more blood because it is contracting faster and more forcefully. Therefore, symptoms occur when the patient exerts themselves and goes away with rest.

If a blockage is very critical (for example a 99% blockage) the patient may have symptoms even at rest.

The duration of chest pain is important. A twinge of chest pain lasting a second is less likely to be a significant problem. A sustained chest pain lasting minutes is more likely to represent decreased blood flow to the heart.

If you are think you are having a heart attack, the safest course of action is to dial 9-1-1. Even if you have been evaluated and told that nothing is wrong, you should still seek medical attention through 9-1-1 and the Emergency Department.