From the Guidelines
The recommended initial beta-blocker for a patient with atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) is carvedilol, metoprolol succinate, or bisoprolol, as these medications have demonstrated mortality benefits in HFrEF patients and can provide rate control for atrial fibrillation. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, the use of one of these three beta-blockers is recommended to reduce mortality and hospitalizations in patients with HFrEF. For atrial fibrillation rate control, it is suggested to start with low doses and titrate gradually: carvedilol 3.125 mg twice daily, metoprolol succinate 25 mg daily, or bisoprolol 1.25 mg daily. The dose can be increased every 2 weeks as tolerated until reaching target doses (carvedilol 25-50 mg twice daily, metoprolol succinate 200 mg daily, or bisoprolol 10 mg daily) or adequate heart rate control is achieved.
Key Considerations
- Monitor for hypotension and bradycardia during titration, as beta-blockers can exacerbate these conditions.
- Beta-blockers work by blocking beta-adrenergic receptors, reducing sympathetic stimulation of the heart, which improves cardiac function, reduces ventricular remodeling, and controls ventricular rate in atrial fibrillation.
- The 2020 ACC/AHA clinical performance and quality measures for adults with heart failure also support the use of these beta-blockers in patients with HFrEF, unless contraindicated, to reduce morbidity and mortality 1.
- Initiation of beta-blocker therapy should be done after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents, and should be started at a low dose in stable patients.
Dosage and Titration
- Carvedilol: start with 3.125 mg twice daily, increase to 25-50 mg twice daily as tolerated.
- Metoprolol succinate: start with 25 mg daily, increase to 200 mg daily as tolerated.
- Bisoprolol: start with 1.25 mg daily, increase to 10 mg daily as tolerated.
- Increase the dose every 2 weeks as tolerated until reaching target doses or adequate heart rate control is achieved.
From the Research
Beta-Blocker Comparison for Afib and HFrEF
- The choice between carvedilol and metoprolol succinate for a patient with atrial fibrillation (afib) and heart failure with reduced ejection fraction (HFrEF) depends on various factors, including the patient's specific condition and medical history.
- According to a study published in the American Heart Journal 2, carvedilol may have a survival benefit over metoprolol succinate in patients with HFrEF.
- Another study published in The American Journal of Cardiology 3 found that higher doses of beta-blockers, including metoprolol succinate and carvedilol, were associated with lower mortality in patients with HFrEF, regardless of the achieved heart rate.
- A systematic review published in the American Journal of Therapeutics 4 found that metoprolol succinate is associated with significant mortality and morbidity benefits in the treatment of HF, but noted that comparative evidence with other beta-blockers is limited.
- A retrospective cohort study published in PLoS ONE 5 found that beta-blocker use, including carvedilol, bisoprolol, and sustained-release metoprolol succinate, was associated with lower heart failure readmission and mortality rates in patients with HFrEF.
Key Findings
- Carvedilol may be associated with improved survival compared to metoprolol succinate in patients with HFrEF 2.
- Higher doses of beta-blockers are associated with lower mortality in patients with HFrEF, regardless of the achieved heart rate 3.
- Metoprolol succinate is associated with significant mortality and morbidity benefits in the treatment of HF, but comparative evidence with other beta-blockers is limited 4.
- Beta-blocker use is associated with lower heart failure readmission and mortality rates in patients with HFrEF 5.