What is the target pulse rate for a patient on bisoprolol (beta blocker) for heart failure?

Target Heart Rate for Patients on Bisoprolol for Heart Failure

The target heart rate for patients on bisoprolol for heart failure should be 50-70 beats per minute (bpm). 1

Rationale for Target Heart Rate

Bisoprolol, a highly selective beta-1 adrenergic receptor blocker, is used in heart failure to reduce mortality and morbidity. The European Society of Cardiology guidelines specifically recommend:

• A target heart rate of 50-70 bpm for patients on bisoprolol for heart failure 1
• This target is based on evidence showing improved outcomes when heart rate is controlled within this range

Dosing and Titration Protocol

Initial Dosing

• Starting dose: 1.25 mg once daily 1
• Begin with this low dose regardless of baseline heart rate (provided it's >50 bpm)
• Monitor heart rate, blood pressure, and clinical status during initiation

Titration Process

• Increase dose at 2-4 week intervals 1
• Double the dose at each titration step (e.g., 1.25 mg → 2.5 mg → 5 mg → 10 mg)
• Continue titration until:
  • Target heart rate of 50-70 bpm is achieved 1
  • Maximum dose of 10 mg daily is reached 1
  • Maximum tolerated dose is reached

Monitoring During Titration

• Check heart rate at each visit before increasing dose
• Do not increase dose if:
  • Heart rate is <50 bpm
  • Patient shows signs of worsening heart failure
  • Patient develops symptomatic hypotension
  • Patient develops excessive bradycardia

Special Considerations

Bradycardia Management

If heart rate drops below 50 bpm with worsening symptoms:

• Halve the dose of bisoprolol 1
• Review other heart rate-slowing medications (digoxin, amiodarone, diltiazem) 1, 2
• Obtain ECG to exclude heart block 1
• Seek specialist advice if severe bradycardia persists 1, 2

Hypotension Management

If symptomatic hypotension occurs:

• Consider reducing doses of other vasodilators (nitrates, ACE inhibitors) 1
• If no signs of congestion, consider reducing diuretic dose 1
• Do not abruptly discontinue bisoprolol unless absolutely necessary 1

Evidence Base

The target heart rate of 50-70 bpm is supported by multiple guidelines and clinical trials:

• The DECREASE studies used bisoprolol with a target heart rate of 50-70 bpm and showed significant reduction in cardiac events 1
• The European Society of Cardiology guidelines specifically recommend this target range for heart failure patients on beta-blockers 1
• Studies have shown that each 10 bpm reduction in heart rate is associated with approximately 30% reduction in risk of cardiac death 1

Important Caveats

• The MERIT-HF trial found that the benefit of beta-blockers in heart failure was independent of baseline heart rate, achieved heart rate, or change in heart rate 3
• The primary goal should be to reach the target dose (10 mg daily for bisoprolol) or maximum tolerated dose, rather than focusing solely on achieving a specific heart rate 3
• Heart rate reduction with bisoprolol is more pronounced during daytime than at night 4
• Abrupt discontinuation of bisoprolol should be avoided due to risk of rebound tachycardia and worsening heart failure 1

By aiming for a heart rate of 50-70 bpm while titrating bisoprolol to the target or maximum tolerated dose, clinicians can optimize outcomes for heart failure patients while minimizing adverse effects.