What are the comparable doses of different beta blockers, such as metoprolol (Lopressor), atenolol (Tenormin), propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), and nebivolol (Bystolic)?

Comparable Doses of Beta Blockers

The comparable target doses of beta blockers for heart failure are: bisoprolol 10 mg once daily, metoprolol succinate CR 200 mg once daily, carvedilol 25-50 mg twice daily (50 mg total daily), and nebivolol 10 mg once daily. 1

Evidence-Based Beta Blockers for Heart Failure

Beta blockers are a cornerstone of heart failure management, particularly for patients with reduced ejection fraction (HFrEF). According to guidelines, only specific beta blockers have been proven to reduce mortality in heart failure:

• Bisoprolol: Initial dose 1.25 mg once daily, target dose 10 mg once daily
• Metoprolol succinate CR: Initial dose 12.5-25 mg once daily, target dose 200 mg once daily
• Carvedilol: Initial dose 3.125 mg twice daily, target dose 25-50 mg twice daily
• Nebivolol: Initial dose 1.25 mg once daily, target dose 10 mg once daily 1

Beta Blockers for Hypertension

For hypertension management, comparable doses include:

• Atenolol: 25-100 mg daily (1-2 doses)
• Metoprolol tartrate: 100-200 mg daily (2 doses)
• Propranolol: 80-160 mg daily (2 doses)
• Bisoprolol: 2.5-10 mg once daily
• Carvedilol: 12.5-50 mg daily (2 doses)
• Nebivolol: 5-40 mg once daily 1

Titration and Administration

When initiating beta blockers for heart failure:

1. Start with a very low dose (see initial doses above)
2. Titrate gradually, doubling the dose every 1-2 weeks if well tolerated
3. Aim for target doses shown to be effective in clinical trials
4. Monitor for symptoms of worsening heart failure, hypotension, and bradycardia 1

Selectivity and Special Properties

Beta blockers differ in their selectivity and additional properties:

• Cardioselective (β1-selective): Bisoprolol, metoprolol, atenolol, nebivolol
• Non-selective: Propranolol, carvedilol
• Combined alpha and beta blockers: Carvedilol, labetalol
• Vasodilatory properties: Carvedilol, nebivolol 1

Comparative Effectiveness

While all four evidence-based beta blockers (bisoprolol, carvedilol, metoprolol succinate, and nebivolol) reduce mortality in heart failure, there are some differences:

• Carvedilol may have slightly greater mortality benefit compared to β1-selective agents in some studies 2
• However, other research suggests similar effects on mortality among bisoprolol, carvedilol, and metoprolol succinate 3
• Nebivolol may be less effective than the other three in elderly patients with systolic heart failure 4

Clinical Pearls and Pitfalls

• Metoprolol formulation matters: Only metoprolol succinate (extended-release) is proven for heart failure, not metoprolol tartrate
• Dosing frequency: Carvedilol requires twice-daily dosing while bisoprolol, metoprolol succinate, and nebivolol can be given once daily
• Contraindications: Avoid beta blockers in patients with severe bronchospastic disease, symptomatic bradycardia, or hypotension
• Discontinuation: Never abruptly stop beta blockers; always taper to avoid rebound effects
• Decompensated heart failure: If inotropic support is needed in patients on beta blockers, phosphodiesterase inhibitors are preferred 1

Target Doses for Heart Failure with Reduced Ejection Fraction

For optimal outcomes in HFrEF, aim for these evidence-based target doses:

• Bisoprolol: 10 mg once daily
• Carvedilol: 25 mg twice daily (50 mg total daily)
• Carvedilol extended release: 80 mg once daily
• Metoprolol succinate sustained release: 200 mg once daily 1

Remember that achieving at least 50% of the target dose is associated with improved outcomes, so titrate to the highest tolerated dose within the target range.