What is the comparison between metoprolol (Beta-1 selective Beta blocker) and bisoprolol (Beta-1 selective Beta blocker) in clinical trials for heart failure?

From the Guidelines

Bisoprolol and metoprolol succinate are both recommended for the treatment of heart failure, with bisoprolol having similar mortality reduction benefits as metoprolol succinate, as demonstrated in landmark clinical trials such as the CIBIS-II and MERIT-HF trials, respectively, with a 30-40% reduction in mortality and hospitalizations, as noted in 1 and 1.

Key Considerations

• Both bisoprolol and metoprolol succinate should be initiated at low doses and titrated to target doses, with close monitoring of heart rate, blood pressure, and symptoms, as recommended in 1 and 1.
• The choice between bisoprolol and metoprolol succinate may depend on patient-specific factors, such as comorbidities, tolerance, and formulary availability, as well as cost considerations.
• Bisoprolol offers advantages of once-daily dosing and higher beta-1 selectivity, making it potentially better for patients with respiratory conditions, as noted in 1.

Dosing and Titration

• Bisoprolol is typically started at 1.25 mg daily and gradually titrated to a target dose of 10 mg daily.
• Metoprolol succinate begins at 12.5-25 mg daily with a target of 200 mg daily.
• Both medications should be doubled every 2 weeks as tolerated, with close monitoring of heart rate, blood pressure, and symptoms, as recommended in 1 and 1.

Clinical Recommendations

• The use of beta blockers, including bisoprolol and metoprolol succinate, is recommended for all patients with current or prior symptoms of heart failure with reduced ejection fraction (HFrEF), unless contraindicated, to reduce morbidity and mortality, as noted in 1 and 1.
• Guideline-directed medical therapy (GDMT) should be initiated and adjusted no more frequently than every 2 weeks to target doses (or maximally tolerated doses), as recommended in 1.

From the Research

Comparison of Metoprolol and Bisoprolol in Heart Failure Clinical Trials

• Both metoprolol and bisoprolol are evidence-based beta-blockers recommended for the treatment of systolic heart failure (HF) 2.
• Clinical trials have consistently shown the benefits of beta-blocker treatment in patients with chronic heart failure, with bisoprolol being one of the first beta-blockers shown to improve survival in an outcome trial 3, 4, 5.
• The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II) demonstrated that bisoprolol reduces all-cause mortality and sudden death in patients with chronic HF compared to placebo, regardless of age, NYHA functional class, and co-morbidities 3, 4, 5.
• Metoprolol succinate is also indicated for the treatment of chronic HF, but there is no evidence to suggest that one evidence-based beta-blocker is preferential over the others in women or the elderly with HF 2.
• Carvedilol may confer greater benefit in HF patients with diabetes and atrial fibrillation, as well as in African American patients 2.
• Bisoprolol has been shown to be effective and well-tolerated in patients with stable chronic heart failure, and its use is considered a standard treatment option when selecting a beta-blocker for use in combination with ACE inhibitors and diuretics 5, 6.

Efficacy and Safety of Bisoprolol

• Bisoprolol has been shown to increase left ventricular function and reduce heart rate, with increases in heart rate variability also seen 5.
• The CIBIS and CIBIS-II trials demonstrated that bisoprolol reduces all-cause mortality and cardiovascular deaths, and improves survival in patients with chronic HF 3, 4, 5.
• Bisoprolol is generally well-tolerated in patients with chronic heart failure, with common adverse events including dizziness, bradycardia, hypotension, and fatigue 5.

Clinical Trials and Recommendations

• The current standard of care is to treat all heart failure patients according to the recommendations for the overall population 2.
• Further data are needed to provide evidence-based recommendations for the use of beta-blockers in special populations, such as women, the elderly, African Americans, patients with diabetes, and patients with atrial fibrillation 2.
• Bisoprolol is considered a first-line beta-blocker for patients with systolic heart failure, based on its efficacy and safety profile 6.