From the Guidelines
Beta blockers that are effective for blood pressure control include metoprolol, bisoprolol, carvedilol, and nebivolol, with carvedilol being a preferred option due to its additional vasodilating properties and mortality reduction benefits, as shown in the Carvedilol or Metoprolol European Trial (COMET) 1. The most effective beta blockers for blood pressure control are those that have been proven to reduce mortality in patients with heart failure, such as metoprolol succinate, bisoprolol, carvedilol, and nebivolol.
- Metoprolol succinate is a commonly prescribed cardioselective beta blocker that has been shown to reduce mortality in patients with heart failure, with a 34% reduction in mortality in the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF) 1.
- Bisoprolol is another long-acting beta blocker that has been shown to reduce mortality in patients with heart failure, with a 32% reduction in all-cause mortality in the Cardiac Insufficiency Bisoprolol Study (CIBIS-II) 1.
- Carvedilol is a beta blocker with additional alpha-blocking properties, which provides vasodilating effects and has been shown to reduce mortality in patients with heart failure, with a 17% greater mortality reduction compared to metoprolol tartrate in the COMET trial 1.
- Nebivolol is a beta 1-selective beta blocker with vasodilating properties, which has been shown to reduce all-cause mortality or cardiovascular hospital admissions in patients with heart failure, as demonstrated in the Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with heart failure (SENIORS) trial 1. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, beta blockers are recommended as a fourth-line treatment option for resistant hypertension, with a preference for vasodilating beta blockers such as carvedilol, nebivolol, or labetalol 1.
- The guidelines recommend that beta blockers be combined with other major BP-lowering drug classes when there are compelling indications for their use, such as angina, post-myocardial infarction, or heart failure with reduced ejection fraction (HFrEF) 1.
- The guidelines also recommend that medications be taken at the most convenient time of day for the patient to establish a habitual pattern of medication taking and improve adherence 1.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Hypertension The initial dose of atenolol is 50 mg given as one tablet a day either alone or added to diuretic therapy.
Clinical Studies Hypertension In controlled clinical studies, metoprolol has been shown to be an effective antihypertensive agent when used alone or as concomitant therapy with thiazide-type diuretics, at oral dosages of 100 to 450 mg daily
The mechanism of the antihypertensive effects of beta-blocking agents has not been fully elucidated However, several possible mechanisms have been proposed: (1) competitive antagonism of catecholamines at peripheral (especially cardiac) adrenergic neuron sites, leading to decreased cardiac output;
The beta blockers that are effective for blood pressure (BP) control are:
- Atenolol: The initial dose is 50 mg given as one tablet a day either alone or added to diuretic therapy 2
- Metoprolol: Effective antihypertensive agent when used alone or as concomitant therapy with thiazide-type diuretics, at oral dosages of 100 to 450 mg daily 3
From the Research
Effective Beta Blockers for Blood Pressure Control
The following beta blockers have been found to be effective for blood pressure control:
- Bisoprolol: shown to be effective in reducing all-cause death and sudden death in patients with heart failure 4, 5
- Carvedilol: effective in improving survival in patients with systolic heart failure 4, 5, 6
- Metoprolol succinate: effective in reducing all-cause death and sustaining 24-hour blood pressure control 4, 5, 7, 8
- Nebivolol: may be effective in improving survival in patients with systolic heart failure, but its efficacy is diminished by its intrinsic sympathomimetic activity 4, 5, 6
Comparison of Beta Blockers
Studies have compared the efficacy of different beta blockers in controlling blood pressure:
- Metoprolol succinate was found to be more effective than atenolol in sustaining 24-hour and early morning blood pressure reductions 8
- The combination of metoprolol succinate and felodipine was found to have additive effects on blood pressure control 7
Initiation and Titration of Beta Blockers
Beta blockers should be initiated at low doses and titrated upward as tolerated to achieve the desired clinical effects on heart rate and symptom control 4, 6