From the Guidelines
Beta-blockers are the primary medications recommended for heart rate control in heart failure patients, and should be initiated at low doses and gradually titrated upward every 2 weeks as tolerated, as they reduce mortality and morbidity by blocking sympathetic stimulation, reducing heart rate, and allowing better ventricular filling 1. The recommended beta-blockers for heart rate control in heart failure patients include metoprolol succinate 25-200 mg daily, carvedilol 3.125-25 mg twice daily, or bisoprolol 1.25-10 mg daily.
- These medications should be used with caution in patients with overt congestion, hypotension, or heart failure with reduced left ventricular ejection fraction.
- Digoxin (0.125-0.25 mg daily) can be added for additional rate control, particularly in patients with atrial fibrillation and heart failure, though it does not improve mortality.
- Dose adjustments are necessary for patients with renal impairment.
- Non-dihydropyridine calcium channel blockers like verapamil and diltiazem should be avoided in heart failure with reduced ejection fraction as they can worsen cardiac function. Some key points to consider when using these medications include:
- Regular monitoring of heart rate, blood pressure, and symptoms is essential during medication titration.
- Target heart rates are typically 50-70 beats per minute at rest.
- Electrolytes, particularly potassium and magnesium, should be maintained at normal levels to prevent arrhythmias, especially when using digoxin 1.
From the FDA Drug Label
Ivabradine tablets are indicated to reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤ 35%, who are in sinus rhythm with resting heart rate ≥ 70 beats per minute and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use.
The recommended medications for heart rate (HR) control in patients with heart failure (HF) include:
- Ivabradine: indicated to reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤ 35% 2
- Beta-blockers: patients should be on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use 2 Key considerations for HR control in HF patients:
- Resting heart rate: ≥ 70 beats per minute 2
- Left ventricular ejection fraction: ≤ 35% 2
- Sinus rhythm: patients should be in sinus rhythm 2
From the Research
Recommended Medications for Heart Rate Control in Heart Failure
The following medications are recommended for heart rate control in patients with heart failure:
- Beta-blockers, specifically bisoprolol, carvedilol, and metoprolol succinate, which have been proven to reduce mortality and hospitalization in patients with Class II to IV heart failure 3, 4, 5
- Carvedilol may be the preferred beta-blocking agent due to its unique pharmacological profile and potentially relevant ancillary properties 3
- Metoprolol tartrate and nebivolol may also be used, although the evidence is limited 5
Initiation and Titration of Beta-Blockers
- The initiating dose of beta-blockers should be very low (1.25 mg bisoprolol, 3.125 mg carvedilol, 12.5 mg metoprolol succinate) and increased gradually over weeks 5
- The target dose should be the maximum tolerated for adequate bradycardia, as the treatment benefit appears proportional to the magnitude of heart rate reduction 5
Comparison of Beta-Blockers
- Carvedilol and metoprolol succinate have similar effects in reducing all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF) 6
- Bisoprolol and carvedilol may be associated with lower mortality compared to metoprolol succinate, although the results are not consistent across all studies 7
- The choice of beta-blocker may not have a significant impact on all-cause mortality in patients with chronic heart failure (CHF) 7