====== Carvedilol ======

Carvedilol is a 3rd-generation beta-blocker with combined β1, β2, and α1 blockade.

It reduces heart rate, contractility, and systemic vascular resistance.

Classification:
• 3rd Generation (Vasodilating)
• Nonselective β-blocker
• α1-blocking properties
• No intrinsic sympathomimetic activity (ISA)

→ [[cardio:beta_blockers:start|Beta-Blockers Overview]]

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===== Mechanism of Action =====

Blocks:

• β1 receptors → ↓ Heart rate, ↓ contractility  
• β2 receptors → Potential bronchospasm risk  
• α1 receptors → Vasodilation (↓ SVR)

Net Effects:

• ↓ Cardiac output  
• ↓ Systemic vascular resistance  
• ↓ Blood pressure  
• ↓ Myocardial oxygen demand  

Because of α1 blockade, carvedilol lowers afterload more than pure β1 blockers.

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===== Indications =====

==== Heart Failure (HFrEF) ★ ====

• Proven mortality benefit  
• Reduces hospitalizations  
• Part of guideline-directed medical therapy (GDMT)

→ [[cardio:heart_failure:start|Heart Failure Module]]

Evidence-based HFrEF beta-blockers:

• ★ [[cardio:beta_blockers:carvedilol|Carvedilol]]
• ★ [[cardio:beta_blockers:metoprolol|Metoprolol Succinate]]
• ★ [[cardio:beta_blockers:bisoprolol|Bisoprolol]]

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==== Hypertension ====

• Effective due to combined α and β blockade  
• Not first-line for uncomplicated HTN  

→ [[cardio:hypertension:start|Hypertension Module]]

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==== Post-Myocardial Infarction ====

• Reduces remodeling  
• Improves survival  

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==== Portal Hypertension ====

• Used to reduce variceal bleeding risk  
• Decreases portal pressure  

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===== Dosing Considerations in HFrEF =====

• Start low  
• Titrate slowly  
• Initiate only when patient is euvolemic  
• Do NOT start during acute decompensation  

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===== Adverse Effects =====

• Bradycardia  
• Hypotension  
• Dizziness  
• Fatigue  
• Bronchospasm (β2 blockade)  
• Masked hypoglycemia  

Orthostatic hypotension more common than with pure β1 blockers due to α1 blockade.

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===== Contraindications =====

• Severe bradycardia  
• High-grade AV block (without pacemaker)  
• Cardiogenic shock  
• Acute decompensated heart failure  

Use caution in:
• Asthma  
• Severe hypotension  

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===== Carvedilol vs Metoprolol =====

Carvedilol:
• β1 + β2 + α1 blockade  
• Reduces SVR  
• More blood pressure lowering  
• More orthostasis risk  

[[cardio:beta_blockers:metoprolol|Metoprolol]]:
• β1 selective  
• No α1 blockade  
• Less orthostasis  

Both reduce mortality in HFrEF (succinate form for metoprolol).

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===== Clinical Pearls =====

✔ Mortality-reducing in HFrEF  
✔ Provides afterload reduction via α1 blockade  
✔ Start low, titrate slowly in HF  
✔ Avoid in acute decompensated HF  
✔ More orthostatic hypotension than metoprolol  

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Related:

→ [[cardio:beta_blockers:start|Beta-Blockers Overview]]
→ [[cardio:heart_failure:start|Heart Failure Module]]
→ [[cardio:hypertension:start|Hypertension Module]]
→ [[cardio:intro:start|Return to Cardiovascular Modules]]