Obstacles to the initiation of β blockers for heart failure in a specialised clinic within a district general hospital

β Adrenergic receptor blockers (β blockers) are indicated for patients with mild to moderate heart failure (New York Heart Association (NYHA) class II and III) of ischaemic or non-ischaemic aetiology.1 The evidence for their use in stable patients equals or surpasses that for the angiotensin converting enzyme (ACE) inhibitors. In the UK, estimates suggest that 85% of heart failure patients are eligible for treatment with β blockers. Studies show that the proportion actually taking a β blocker for definite heart failure is around 11%. What remains unclear, outside of clinical trials, is the applicability of β blocker use in the general population with stable heart failure. We report our experience from a district general hospital on the feasibility of routine prescription of β blockers as add-on treatment for stable heart failure. Patients with an established diagnosis of cardiac failure were recruited consecutively, over a nine month period, from the cardiology outpatient clinics. Patients attended a specialist nurse run outpatient clinic with medical supervision at the point of drug prescription. Contraindications to initiating treatment with β blockers included bradycardia (<50 beats/min) or high degrees of atrioventricular block unprotected by pacemaker implantation, blood pressure of < 90 mm Hg systolic, significant reversible airways disease (requiring regular use of bronchodilator treatment), and a previous intolerance of β blockers. If these conditions were satisfied then 1.25 mg of bisoprolol was administered. Pulse and blood pressure recordings were monitored for four hours. Patients were advised that they might experience a transient worsening of their symptoms. At each subsequent visit, the dose of bisoprolol was increased successively to 2.5 mg, 3.75 mg, 5.0 mg, 7.5 mg and 10 mg, according to tolerance and as used in CIBIS II (cardiac insufficiency bisoprolol study II).2 We recruited 100 consecutive patients (68 male) with stable cardiac failure …