Gibt es differenzialtherapeutische Unterschiede?

Zusammenfassung

Nur für die neurohumoral wirksamen ACE-Hemmer und Beta-Blocker haben mehrere randomisierte kontrollierte klinische Studien eine Verbesserung der Symptomatik und ein verlängertes Überleben chronisch herzinsuffizienter Patienten belegt. Dabei sollte die Therapie mit Beta-Blockern bei Patienten mit eingeschränkter linksventrikulärer Funktion niedrig dosiert begonnen werden, um dann über mehrere Wochen bis Monate bis zur Zieldosis auftitriert zu werden. Bevor allerdings eine Therapie initiiert wird, sollte sichergestellt sein, dass die Patienten seit mindestens zwei Wochen stabil sind, eine vollständige Basistherapie (ACE-Hemmer, Diuretika, gegebenenfalls Digitalis bzw. Aldactone) erhalten und kein akut gesteigerter Diuretika-Verbrauch vorliegt. Bisher wurde die symptom- und überlebensverlängernde Wirkung der Therapie mit Beta-Rezeptorenblockern bei chronisch herzinsuffizienten Patienten nur für die β₁-selektiven Antagonisten Metoprolol und Bisoprolol sowie für den nichtselektiven Beta-Rezeptorantagonisten Carvedilol nachgewiesen. Der Nutzen einer zusätzlichen Beta-Blocker-Therapie betrifft insbesondere Patienten mit Diabetes mellitus. Nicht eingesetzt werden sollten die Substanzen bei Patienten mit Asthma bronchiale, Erkrankungen des Sinusknotens, höhergradigen AV-Blockierungen, fortgeschrittener arterieller Verschlusskrankheit und hypotonen Blutdruckwerten unter 100 mmHg.

Summary

Increasing evidence has been provided by numerous studies that modulation of the neurohumoral system leads to improvement in symptoms and prognosis in patients with chronic heart failure. This has been demonstrated for the use of ACE-inhibitors as well of beta-adrenoceptor-blockers. Both β₁-selective antagonists (metoprolol, bisoprolol) as well as the non selective beta-blocker carvedilol showed beneficial effects on symptoms and prognosis in placebo controlled randomized trials. Beta-blocker therapy should be started at very low doses. Initial doses are often doubled during the second week, which subsequent titration at intervals of two weeks or longer; several months may be required to achieve the maximal tolerated doses in patients with previous decompensation. Before starting beta-blocker therapy, patients should be on ACE-inhibitors and diuretics for at least two weeks stable. A common reason for limiting dose escalation is bradycardia and a heart rate bellow 60 beats per minute. The main contraindications are bronchospasm and bradycardia. Especially in patients with diabetes mellitus Beta-blocker treatment most effectively improve symptoms and prognosis.

Key Words

beta-adrenoceptor-blocker - chronic heart failure - non selectiv beta-blocker - β₁-selective beta-blocker

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1 carvedilol or metroprolol evaluation trial

2 metoprolol randomized intervention trial in congestive heart failure

3 cardiac insufficiency bisoprolol study

4 betablocker evaluation of survival trial

5 carvediolol prospective randomized cumulative survival trial

6 study of effects of nebivolol intervention on outcome and rehospitalization in seniors with heart failure

7 carvedilol ACE inhibitor remodeling mild heart failure evaluation

Anschrift des Verfassers