From the Guidelines
Beta blockers are strongly recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce morbidity and mortality. The most recent and highest quality study, 1, published in 2013, supports the use of beta blockers in HFrEF patients, with a Level of Evidence: A. According to this study, the use of one of the three beta blockers proven to reduce mortality (eg, bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated.
Key Points to Consider
- The four evidence-based beta blockers for heart failure are carvedilol, metoprolol succinate, bisoprolol, and nebivolol.
- Treatment should be initiated at low doses and gradually uptitrated every 2 weeks as tolerated until reaching target doses or maximum tolerated doses.
- Before starting beta blockers, patients should be clinically stable with no signs of fluid overload.
- During initiation and uptitration, monitor for potential side effects including bradycardia, hypotension, and worsening heart failure symptoms.
Benefits of Beta Blockers
- Improve survival by reducing mortality, as shown in a meta-analysis of over 10,000 patients with heart failure, which found a consistent 30% reduction in mortality 1.
- Reduce hospitalizations by 40%, as estimated in the same meta-analysis 1.
- Reverse cardiac remodeling in heart failure by blocking harmful sympathetic nervous system activation, reducing heart rate, improving myocardial energetics, and preventing arrhythmias.
- Should be used in conjunction with other guideline-directed medical therapies, including ACE inhibitors/ARBs/ARNI, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, for optimal outcomes.
From the FDA Drug Label
WARNINGS Heart Failure Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock. If signs or symptoms of heart failure develop, treat the patient according to recommended guidelines. It may be necessary to lower the dose of metoprolol or to discontinue it
- Beta blockers like metoprolol can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock.
- If signs or symptoms of heart failure develop, the dose of metoprolol may need to be lowered or discontinued.
- The patient should be treated according to recommended guidelines if heart failure develops 2.
From the Research
Beta Blocker Use in Heart Failure
- Beta blockers are a cornerstone of treatment for heart failure with reduced ejection fraction (HFrEF) 3, 4
- Studies have shown that beta blockers can reduce cardiac mortality and morbidity in patients with HFrEF 4, 5
- However, beta blockers are often underutilized or prescribed at lower than recommended dosages due to concerns about adverse effects 4
Benefits of Beta Blockers in HFrEF
- A study published in 2025 found that adherence to maximal target doses of beta-blocker therapy significantly reduces the hazard of death or major adverse cardiac events (MACE) in patients with HFrEF 3
- Another study published in 2015 reviewed available data and found that beta blockers are well-tolerated in patients with HFrEF, despite concerns about adverse effects 4
- A study published in 2020 found that evidence-based beta blocker use was associated with lower heart failure readmission and mortality, but not all-cause readmission, among Medicare beneficiaries hospitalized for HFrEF 5
Use of Beta Blockers in Heart Failure with Preserved Ejection Fraction (HFpEF)
- A study published in 2018 found that high-dose beta-blocker use was associated with a significantly lower risk of death in patients with HFpEF and elevated heart rate 6
- However, another study published in 2014 found that beta blockers had no association with the primary composite endpoint of all-cause mortality or HF rehospitalization in older adults with HFpEF 7
Dosage and Outcomes
- Studies have shown that high-dose beta-blocker use can be beneficial in patients with HFrEF and HFpEF, but the optimal dosage and outcomes are still being researched 3, 6, 5
- A study published in 2025 found that maximal doses of beta-blockers did not result in a significant decrease in resting heart rate, but were associated with a reduced hazard of death or MACE 3