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 car vedilol use in patients on inotrope therapy. We present our experience with carvedilol titration in New York Heart Association (NYHA) class IIIb/IV pa tients stabilized on milrinone therapy, as a nonrandomized study with a par allel control group of patients never on inotropes. These patients achieved volume control and stabilization of their symptoms during the course of mi lrinone therapy. Methods and Results Seventeen patients in class IIIb/IV CHF (group 1) on in termittent intravenous milrinone therapy and 15 patients in class II/IIIa c ompensated CHF (group 2) on standard triple heart failure therapy were titr ated on carvedilol. Success and adverse events during titration were compar ed between the 2 groups. Fifteen (88%) patients in group 1 and 14 (93%) pat ients 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 (2 5 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%) patie nts 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 af ter carvedilol titration, whereas the rest of the patients had reduction in the frequency of infusion. Ten (63%) patients in group 1 improved by one o r more functional classes. Conclusions Patients in NYHA class IIIb/IV who are treated with inotropic t herapy can be titrated on carvedilol after reaching a stable state while on milrinone and standard oral drugs. Most of these patients can be successfu lly weaned off of milrinone or have decreased frequency of infusions and de monstrate improved functional status. Prospective randomized trials are req uired to evaluate these observations made in a limited number of patients i n class IIIb and IV CHF because the combination of milrinone and beta -bloc kers has never been adequately evaluated.