Beta Blocker Dosage Regimens for Hypertension, Heart Failure, and Arrhythmias
Beta blockers should be started at low doses and gradually titrated upward every 1-2 weeks to target doses or maximum tolerated doses, with specific regimens varying by indication and specific agent.
Heart Failure Beta Blocker Regimens
Beta blockers with proven mortality benefit in heart failure include:
| Beta-blocker | Starting dose (mg) | Target dose (mg) | Titration scheme |
|---|---|---|---|
| Bisoprolol | 1.25 once daily | 10 once daily | Double dose every 2 weeks |
| Carvedilol | 3.125 twice daily | 25-50 twice daily | Double dose every 2 weeks |
| Metoprolol CR/XL | 12.5-25 once daily | 200 once daily | Double dose every 2 weeks |
| Nebivolol | 1.25 once daily | 10 once daily | Double dose every 2 weeks |
Heart Failure Initiation Protocol 1:
- Start only in stable patients (not during acute decompensation)
- Patient should be on background ACE inhibitor therapy if not contraindicated
- Begin with low dose (see table above)
- Double dose at 2-week intervals if well tolerated
- Monitor heart rate, blood pressure, and symptoms at each visit
- Check blood chemistry 12 weeks after initiation and after final dose titration
- Aim for target dose or highest tolerated dose
Management of Side Effects in Heart Failure 1:
- For worsening congestion: Increase diuretic dose first; if ineffective, halve beta blocker dose
- For bradycardia (<50 bpm) with symptoms: Halve beta blocker dose, review other rate-slowing medications
- For symptomatic hypotension: Reconsider need for nitrates/vasodilators, possibly reduce diuretic if no congestion
- For serious deterioration: Halve dose or temporarily stop beta blocker and seek specialist advice
Hypertension Beta Blocker Regimens
For hypertension, beta blockers can be dosed as follows:
| Beta-blocker | Initial dose | Target/Maximum dose | Frequency |
|---|---|---|---|
| Acebutolol [2] | 400 mg | 400-800 mg (max 1200 mg) | Daily or twice daily |
| Atenolol [3] | 50 mg | 50-100 mg | Once daily |
| Metoprolol [4,3] | 50-100 mg | 100-200 mg | Once or twice daily |
| Carvedilol [5] | 6.25 mg | 25 mg | Twice daily |
Hypertension Considerations:
- Start with lower doses in elderly patients (half the usual starting dose) 2
- Maximal blood pressure reduction is often achieved with moderate doses; higher doses may not provide additional benefit 3
- Once-daily dosing may be sufficient for many patients with hypertension 4
- Newer vasodilating beta blockers (like carvedilol) may have more favorable metabolic profiles 6, 7
Arrhythmia Beta Blocker Regimens
For ventricular arrhythmias:
- Acebutolol 2: Start with 200 mg twice daily, increase gradually to 600-1200 mg/day
For atrial fibrillation with heart failure:
- Use the heart failure dosing regimens above
- Beta blockers slow ventricular rate and improve symptoms 1
Important Monitoring Parameters
- Heart rate (target >50 bpm)
- Blood pressure (watch for symptomatic hypotension)
- Signs of fluid retention (weight gain, edema)
- Symptoms of fatigue or worsening heart failure
- Electrolytes and renal function
Common Pitfalls to Avoid
- Abrupt discontinuation: Never stop beta blockers suddenly due to risk of rebound ischemia, infarction, and arrhythmias 1
- Inadequate titration: Many patients remain on suboptimal doses; aim for target doses when possible 1
- Starting at too high a dose: Always begin with low doses to minimize side effects
- Failure to recognize beta blocker differences: Not all beta blockers have proven mortality benefit in heart failure; use only those with evidence 1
- Overlooking elderly patients: Older patients have approximately 2-fold increase in bioavailability and require lower maintenance doses 2
Special Considerations
- Heart failure patients: Only bisoprolol, carvedilol, and metoprolol succinate CR/XL have proven mortality benefit 1
- Diabetic patients: Vasodilating beta blockers may have less impact on glycemic control 6, 7
- Elderly: Use lower doses and titrate more slowly 2
- Post-MI patients: Beta blockers reduce mortality; carvedilol showed 23% risk reduction in all-cause mortality 5
Remember that some beta blocker is better than no beta blocker in heart failure patients, even if target doses cannot be achieved 1.