What is the role of beta blockers, specifically bisoprolol (Beta-1 selective blocker), in Guideline-Directed Medical Therapy (GDMT) for patients with heart conditions?

From the Guidelines

Bisoprolol is a cornerstone of Guideline-Directed Medical Therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) and should be used in all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality. The recommended starting dose is 1.25 mg once daily, with gradual titration every 1-2 weeks as tolerated to a target dose of 10 mg daily 1. When initiating bisoprolol, patients should be in a relatively stable condition, not experiencing acute decompensation. Monitor blood pressure, heart rate, and symptoms during titration, as some patients may experience temporary worsening of heart failure symptoms, fatigue, or hypotension. Bisoprolol works by blocking beta-1 adrenergic receptors in the heart, reducing heart rate, contractility, and myocardial oxygen demand while improving ventricular filling time. This leads to reverse remodeling of the left ventricle over time.

Key Considerations

• Bisoprolol should be used alongside other GDMT components including ACE inhibitors or ARBs (or ARNI), mineralocorticoid receptor antagonists, and SGLT2 inhibitors when appropriate.
• If a patient cannot tolerate bisoprolol, alternative beta-blockers with proven mortality benefit in heart failure include carvedilol and metoprolol succinate 1.
• The evidence base for β-blockers in heart failure has been established only for some β-blockers (bisoprolol, metoprolol succinate, carvedilol, and nebivolol), and therapy in patients who develop heart failure while already receiving treatment for a comorbid condition should be switched to one of these β-blockers 1.

Clinical Recommendations

• Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents.
• Beta-blocker therapy should be initiated at a low dose and only in stable patients.
• Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. Some key points to consider when using bisoprolol in patients with HFrEF include:
• The importance of gradual titration to minimize adverse effects
• The need for close monitoring of blood pressure, heart rate, and symptoms during titration
• The potential for temporary worsening of heart failure symptoms, fatigue, or hypotension during titration
• The importance of using bisoprolol in combination with other evidence-based therapies for HFrEF.

From the FDA Drug Label

In general, beta-blocking agents should be avoided in patients with overt congestive failure However, in some patients with compensated cardiac failure it may be necessary to utilize them. In such a situation, they must be used cautiously. The most prominent effect of bisoprolol fumarate is the negative chronotropic effect, resulting in a reduction in resting and exercise heart rate. Factors which may be involved include: 1. Decreased cardiac output, 2. Inhibition of renin release by the kidneys, 3 Diminution of tonic sympathetic outflow from the vasomotor centers in the brain.

The role of beta blockers, specifically bisoprolol (Beta-1 selective blocker), in Guideline-Directed Medical Therapy (GDMT) for patients with heart conditions is to:

• Reduce resting and exercise heart rate through its negative chronotropic effect
• Decrease cardiac output
• Inhibit renin release by the kidneys
• Diminish tonic sympathetic outflow from the vasomotor centers in the brain However, beta blockers should be used with caution in patients with compensated cardiac failure and avoided in patients with overt congestive failure 2.

From the Research

Role of Beta Blockers in Guideline-Directed Medical Therapy (GDMT)

• Beta blockers, including bisoprolol, are a cornerstone in the treatment of heart failure with reduced ejection fraction (HFrEF) and are recommended for all stable patients with current or previous symptoms of heart failure unless there is a contraindication 3.
• The use of beta blockers, such as bisoprolol, carvedilol, and metoprolol succinate, has been shown to reduce mortality and morbidity in patients with HFrEF 3, 4, 5, 6.
• Bisoprolol, a beta-1 selective blocker, has been specifically shown to reduce all-cause mortality and sudden death in patients with chronic heart failure 3, 6.

Efficacy of Bisoprolol in Heart Failure

• Studies have demonstrated that bisoprolol is effective in reducing mortality and improving outcomes in patients with heart failure, including those with reduced ejection fraction 3, 4, 6.
• Bisoprolol has been shown to be as effective as other beta blockers, such as carvedilol and metoprolol succinate, in reducing mortality in patients with heart failure 4.
• High-dose bisoprolol has been associated with a significantly lower risk of death in patients with heart failure with preserved ejection fraction (HFpEF) and elevated heart rate 7.

Safety and Tolerability of Beta Blockers

• Despite the benefits of beta blockers, their use is often limited by concerns about adverse effects, either perceived or real 5.
• However, studies have shown that beta blockers, including bisoprolol, are generally well-tolerated and safe in patients with heart failure 3, 5.
• The safety and tolerability of beta blockers, including bisoprolol, have been demonstrated in several large-scale randomized clinical trials 5.