What are the recommended beta blockers (beta-adrenergic blocking agents) for patients with Coronary Artery Disease (CAD)?

Recommended Beta Blockers for Coronary Artery Disease

For patients with coronary artery disease (CAD), metoprolol succinate, carvedilol, or bisoprolol are the recommended beta blockers, particularly for those with left ventricular ejection fraction (LVEF) ≤40%. These specific agents have demonstrated mortality benefit in clinical trials 1, 2.

Indications for Beta Blockers in CAD

Beta blocker therapy recommendations depend on specific patient characteristics:

Strongly Recommended (Class I):

• Patients with CAD and LVEF ≤40% (with or without previous MI)
• Within 3 years after myocardial infarction (MI)
• Patients with angina symptoms

Not Recommended:

• Patients with CAD without previous MI or LVEF ≤50%, in the absence of other indications for beta blockers 1

Specific Beta Blockers and Dosing

First-Line Options:

1. Metoprolol succinate (extended-release)

   • Starting dose: 12.5-25 mg once daily
   • Target dose: 200 mg once daily
   • Titration: Increase over weeks to months

2. Carvedilol

   • Starting dose: 3.125 mg twice daily
   • Target dose: 25-50 mg twice daily (based on weight)
   • Titration: Double dose at 2-week intervals as tolerated
   • Additional benefits: Alpha-1 blocking properties, vasodilation, potentially better glycemic profile 2, 3

3. Bisoprolol

   • Starting dose: 1.25 mg once daily
   • Target dose: 10 mg once daily
   • Titration: Increase over weeks to months 2

Patient-Specific Considerations

Post-MI Patients:

• Beta blockers should be started and continued for 3 years in all patients after MI 1
• For patients enrolled within 1 year after MI, beta blockers are associated with lower all-cause death (HR 0.68) and cardiovascular death (HR 0.52) 4

Heart Failure with Reduced Ejection Fraction:

• Beta blockers are essential components of treatment for reducing morbidity and mortality 1, 2
• Specifically use metoprolol succinate, carvedilol, or bisoprolol with titration to target doses 1

Angina Management:

• Either a beta blocker or calcium channel blocker is recommended as first-line antianginal therapy 1
• Beta blockers are effective for symptom relief by reducing myocardial oxygen demand 5, 6

Important Precautions

Contraindications:

• Severe bradycardia or hypotension
• High-grade atrioventricular block
• Heart rate <60/min without functioning pacemaker
• Severe bronchial disease with reactive airway component 2

Monitoring:

• Heart rate (target 50-60 beats/min unless side effects occur)
• Blood pressure
• Signs of worsening heart failure 2

Discontinuation:

• Never abruptly discontinue beta blockers in CAD patients
• Gradual tapering over 1-2 weeks is recommended
• Abrupt discontinuation can cause severe exacerbation of angina, MI, and ventricular arrhythmias 3

Recent Guideline Updates

The 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for chronic coronary disease management 1 has updated recommendations:

1. Long-term beta blocker therapy is not recommended to improve outcomes in CAD patients without:

   • MI in the past year
   • LVEF ≤50%
   • Another primary indication (angina, arrhythmias, hypertension)

2. For patients with LVEF <50%, specifically use sustained-release metoprolol succinate, carvedilol, or bisoprolol with titration to target doses 1

This represents a significant change from previous guidelines that recommended broader use of beta blockers in all CAD patients.