Carvedilol

How it works

It blocks beta-1, beta-2 and alpha-1 adrenoceptors, reducing heart rate and contractility while causing peripheral vasodilatation, which lowers blood pressure and, in heart failure, mitigates chronic sympathetic activation.

Prescribing in practice

• In heart failure it must be initiated at a low dose in a stable patient and titrated slowly, as rapid increases can transiently worsen failure; do not stop abruptly.
• The alpha-blocking effect adds a risk of postural hypotension, particularly with the first dose and after increases.
• Use caution in asthma given non-selective beta-blockade, and it may mask hypoglycaemic warning signs in diabetes.

Monitoring

Monitor heart rate, blood pressure and heart failure status, including for fluid retention, during gradual titration.

Counselling the patient

• Take with food to reduce the chance of dizziness from a rapid drop in blood pressure.
• Do not stop the medicine suddenly without advice.
• Report fainting, marked dizziness, wheeze or worsening breathlessness or swelling.

Evidence & guidelines

Carvedilol reduces mortality in chronic heart failure with reduced ejection fraction, demonstrated in the COPERNICUS trial, and is recommended by NICE for heart failure.