What are the approved beta blockers (beta-adrenergic blocking agents) for the treatment of heart failure?

From the Guidelines

Beta blockers approved for heart failure include carvedilol, metoprolol succinate, and bisoprolol, which are recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality 1. These medications are considered standard therapy for patients with heart failure with reduced ejection fraction (HFrEF).

Key Points

• The typical starting doses are low with gradual titration:
  • Carvedilol starting at 3.125 mg twice daily and titrating to 25-50 mg twice daily
  • Metoprolol succinate starting at 12.5-25 mg daily and titrating to 200 mg daily
  • Bisoprolol starting at 1.25 mg daily and titrating to 10 mg daily
• Titration usually occurs every 2 weeks as tolerated
• These medications work by blocking beta-adrenergic receptors, reducing heart rate and blood pressure, which decreases cardiac workload and oxygen demand
• They also inhibit harmful neurohormonal activation present in heart failure
• Patients should be monitored for potential side effects including bradycardia, hypotension, and worsening heart failure symptoms during initiation and dose increases
• Beta blockers should be initiated when patients are euvolemic and relatively stable, not during acute decompensation
• They have been shown to reduce mortality, hospitalizations, and improve symptoms in heart failure patients when used as part of comprehensive therapy that typically includes ACE inhibitors/ARBs/ARNI and mineralocorticoid receptor antagonists 1.

From the Research

Heart Failure Approved Beta Blockers

• The American College of Cardiology/ American Heart Association recommends the use of β-blockers in chronic HF, especially for bisoprolol, carvedilol, and sustained-release metoprolol succinate 2.
• Bisoprolol, carvedilol, and metoprolol succinate have been clearly proven to reduce mortality and hospitalisation in patients with Class II to IV heart failure 3.
• The use of these three agents should be recommended for all stable subjects with current or previous symptoms of heart failure and heart failure with reduced ejection fraction unless there is any contraindication 2.
• Carvedilol may confer greater benefit in HF patients with diabetes and atrial fibrillation as well as in African American patients 4.

Dosing of Beta Blockers

• Heart failure guidelines recommend that beta blockers be titrated to achieve the target doses shown to be effective in major clinical trials, if tolerated 5.
• Initiating dose should be very low (1.25 mg bisoprolol, 3.125 mg carvedilol, 12.5 mg metoprolol succinate) and increased gradually over weeks 3.
• Treatment benefit appears proportional to magnitude of heart rate reduction and thus target dose should be the maximum tolerated for adequate bradycardia 3.

Special Populations

• There is no evidence that one evidence-based beta-blocker is preferential over the others in women or in the elderly with HF 4.
• Beta-blockers are not contraindicated in patients with coexisting bronchospasm, although the dose may have to be reduced or withheld temporarily 3.
• Even in decompensated heart failure, beta-blockers are not contraindicated although the dose may have to be reduced or withheld temporarily 3.

Quality of Life

• Beta-blocker therapy in patients with heart failure has been shown to improve the quantity of life and, at least in terms of the incidence of hospitalization, to improve the quality of life as well 6.
• Randomized trials have consistently reported a favourable change in NYHA functional class in patients treated with beta-adrenergic blocking drugs: the majority of patients became less symptomatic 6.