Beta-blocker Uptitration in Heart Failure Patients Receiving Cardiac Resynchronization Therapy With Optivol Fluid Status Monitoring System
Overview
- Phase
- Phase 4
- Intervention
- Beta blocker (carvedilol or metoprolol succinate)
- Conditions
- Congestive Heart Failure
- Sponsor
- St. Luke's-Roosevelt Hospital Center
- Enrollment
- 2
- Locations
- 3
- Primary Endpoint
- LVESVI change in patients with CRT/ increased dose of beta-blockers vs CRT and no change in beta-blocker dose.
- Status
- Terminated
- Last Updated
- 10 years ago
Overview
Brief Summary
Many heart failure patients are unable to reach target beta blocker doses. This study will address whether cardiac resynchronization therapy (CRT) will enable uptitration of beta-blockers to target doses and whether it will favorably affect remodeling by reducing left ventricular end systolic volume (LVESV), with measurable clinical benefit, beyond CRT alone (without changes in beta-blocker dose).
Detailed Description
Beta blockers have been proven to have benefit in heart failure (HF) patients with regard to morbidity and mortality. However, initiation and uptitration remains a challenge in many patients. Worsening of heart failure, symptomatic hypotension and symptomatic bradycardia all limit up-titration to the target doses that have been shown to have mortality benefits (carvedilol \[Coreg\] 25 mg bid, metoprolol succinate \[Toprol-XL\] 200 mg qd) in the large clinical trials (COPERNICUS, MERIT-HF). It is debated whether the benefit of beta-blockade is solely due to heart rate reduction or more broadly from the cardiac, central and peripheral effects of blocking sympathetic activity. Clearly, there is a remodeling effect on the dilated ventricle. Furthermore, patients with heart rates of 64 bpm or less are rarely begun on beta-blocker therapy. It is not known whether these patients should be given a pacemaker in order to then safely initiate beta-blocker therapy. It is also clear that isolated right ventricular pacing can have deleterious effects on ventricular dyssynchrony and symptomatic heart failure despite medical therapy. Biventricular pacing (BIVPM), also known as cardiac resynchronization therapy (CRT), is the pacing mode of choice for patients with wide QRS complexes and symptomatic HF. It is hypothesized that CRT therapy allows for increased Beta -blocker dose (or initiation of beta-blocker in patients previously intolerant) with improved NYHA, ejection fraction, and remodeling effects. The synergy between two established heart failure therapies requires further evaluation in a prospective randomized trial.
Investigators
Eligibility Criteria
Inclusion Criteria
- •NYHA III-IV
- •QRS \> 120 msec
- •On medical therapy, but beta blocker dose not @ target (carvedilol 25 bid, metoprolol succinate 200 qd)
Exclusion Criteria
- •QRS \< 120 msec
- •On target beta blocker dose
Arms & Interventions
1
CRT and b-blocker uptitration to target dose
Intervention: Beta blocker (carvedilol or metoprolol succinate)
1
CRT and b-blocker uptitration to target dose
Intervention: CRT (cardiac resynchronization therapy)
2
CRT and continuation of entry b-blocker dose to 6 month evaluation
Intervention: Beta blocker (carvedilol or metoprolol succinate)
2
CRT and continuation of entry b-blocker dose to 6 month evaluation
Intervention: CRT (cardiac resynchronization therapy)
Outcomes
Primary Outcomes
LVESVI change in patients with CRT/ increased dose of beta-blockers vs CRT and no change in beta-blocker dose.
Time Frame: 6 months
Secondary Outcomes
- Comparison of LVESVI changes based on initial beta-blocker dose(6 months)
- LVEDVI(6 months)
- HF Hospitalizations/ Mortality(6 months)
- QOL - NYHA, Minnesota LWHFQ, Symptom Assessment Questionnaire(6 months)
- Correlation of Optivol fluid measurement increases (decreased impedance) with symptomatic worsening of heart failure during beta blocker uptitration(6 months)
- Exercise - 6 minute walk(6 months)
- Ejection fraction(6 months)
- Remodeling(6 months)
- Plasma Brain natriuretic peptide (BNP) change(6 months)
- Optivol measurements (decreased impedance, increase volume index) correlated with the need for adjusting diuretic therapy when uptitrating beta blocker dose(12 months)
- 12 month comparison after Group 2 has been uptitrated.(12 months)
- Evaluation of LVESVI in patients who actually achieve target dose(6 months)
- Functional improvements(6 months)