Beta Blocker Titration

1
Beta Blocker Titration

• Chilliwack Team
• CHF Collaborative

2
The CHF Registry

• 39 CHF patients
• 56 Systolic CHF, 44 Diastolic CHF
• 14 CHF related admissions in the prior year
• 80 on ACE-I or ARBs
• 36 on Beta Blockers
• 63 trial drug
• 0 target dose

3
CHF Guidelines

• Beta Blockers for Systolic CHF
• Drug Start Dose Target
  Dose
• Carvedilol 3.125 mg bid 25 mg bid
• Metoprolol 12.5 mg bid 200 mg SR od
• Bisoprolol 1.25 mg od 10 mg od

4
Goals for Beta Blocker Titration

• Initial Goal
• gt 50 of patients with systolic CHF will be on
  a beta blocker (or ARB if beta blocker
  intolerant)
• Revised Goal
• gt 75 of patients with systolic CHF will be on
  a trial beta blocker with titration to target
  dose (or maximum tolerated dose if intolerant)

5
Barriers to Change - Physician

• Beta blockers are not well tolerated
• Side effects common, especially at higher doses
• Many CHF patients are elderly on multiple drugs
• Adding a beta blocker is adding yet another drug
• The elderly are more susceptible to side effects
  and drug interactions
• Maybe beta blockers are helpful for CHF, but are
  they really necessary?
• Should I really try to achieve those dose
  targets?
• Why fix it if it isnt broken?

6
1st PDSA Cycle

• Plan - Convert NYHC 3 4 patients to target beta
  blocker and titrate dose according to titration
  protocols
• Do NYHC 3 4 patients identified and recalled
  for planned visits
• Study Monitor Na, K, creatinine, weight, BP,
  HR, exercise tolerance, quality of life
• Act If successful in NYHC 3 4 patients,
  spread to NYHC 1 2 patients in CHF registry

7
Results

• NYHC 4 patient improved to NYHC 3
• Renal function improved
• Hyponatremia improved
• Exercise tolerance improved
• Quality of life improved
• Reduced admissions to hospital
• Digoxin discontinued without adverse effect

8
2nd PDSA Cycle

• Plan Convert 75 of CHF patients to trial beta
  blocker and titrate to trial dose
• Do Create beta blocker spreadsheet and use for
  planned CHF visits
• Study Record barriers to beta blocker titration
  and how barriers overcome
• Act Review spreadsheet monthy, assess progress,
  continue planned visits to achieve goal

9
Beta Blocker Spreadsheet

• Patient Identifier, CHF type , NYHC (1-4)
• Initial beta blocker, new beta blocker, dose
• Obstacles to titration
• Overcoming obstacles
• Outcome
• Target beta blocker ? (T/F)
• Trial dose ? (T/F)

10
Barriers to Change - Patient

• Volume Status (too wet, too dry)
• Hypotension
• Bradycardia
• Sick Sinus Syndrome
• Erectile Dysfunction
• COPD/Asthma
• Previously intolerant to beta blockers

11
More Barriers to Change

• Cost of Carvedilol
• Pharmacare - Special Authority
• Side effects
• The frail elderly with cognitive impairment
• How to make the switch

12
Overcoming Barriers

• Appendix 3 of CHF guidelines
• Making the switch
• Atenolol 50 mg od Nadolol 80 mg od
• Metoprolol SR 100 mg od
• Bisoprolol 10 mg od
• Carvedilol 12.5 mg bid
• What about Sotalol?

13
More on Overcoming Barriers

• CHF Collaborative
• Learning sessions
• List Serve
• Shared Care
• Teleconference
• Cardiologist
• Pharmacist Patient Self Management Support

14
The second law of Q.I.

• The act of measurement itself improves
  performance
• Physicians like accurate data and will make
  changes as necessary to improve outcomes it is a
  professional instinct
• Art Macgregor VIHA

15
Outcomes

• Of Systolic Heart Failure Patients
• 95 on ACE-I or ARB
• 73 on beta blocker
• 94 are on trial beta blocker
• 40 are at target dose
• CHF Related Hospital Admissions
• 61 reduction compared to previous year