What are the vasodilatory beta blockers used in patients with reduced Left Ventricular Ejection Fraction (LVEF)?

From the Guidelines

Carvedilol is the preferred vasodilatory beta blocker for patients with reduced left ventricular ejection fraction (LVEF), as it has been proven to reduce mortality and is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality. The use of carvedilol, a vasodilatory beta blocker, is supported by the 2013 ACCF/AHA guideline for the management of heart failure, which recommends the use of one of the three beta blockers proven to reduce mortality, including carvedilol, bisoprolol, and sustained-release metoprolol succinate, for all patients with current or prior symptoms of HFrEF, unless contraindicated 1. Some key points to consider when using carvedilol in patients with reduced LVEF include:

• Starting at a low dose, such as 3.125 mg twice daily, and gradually titrating to a target dose of 25 mg twice daily (or 50 mg twice daily for patients >85 kg)
• Monitoring blood pressure, heart rate, and symptoms during the uptitration period
• The benefits of carvedilol, including reducing the risk of death and the combined risk of death or hospitalization, as well as lessening the symptoms of HF, improving the patient’s clinical status, and enhancing the patient’s overall sense of well-being, as seen in patients with or without CAD and in patients with or without diabetes mellitus, as well as in women and blacks 1. It's worth noting that while nebivolol is also a vasodilatory beta blocker, the most recent and highest quality study, the 2013 ACCF/AHA guideline, specifically recommends carvedilol, bisoprolol, and sustained-release metoprolol succinate, without mentioning nebivolol 1.

From the FDA Drug Label

Carvedilol Tablet should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. is not relevant to the question. In a double-blind trial, 161 children (mean age 6 years, range 2 months to 17 years; 45% less than 2 years old) with chronic heart failure [NYHA class II to IV, left ventricular ejection fraction less than 40% for children with a systemic left ventricle (LV), and moderate-severe ventricular dysfunction qualitatively by echo for those with a systemic ventricle that was not an LV] who were receiving standard background treatment were randomized to placebo or to two dose levels of Carvedilol Tablet. is relevant to the question, vasodilatory beta blockers are used in patients with reduced Left Ventricular Ejection Fraction (LVEF), specifically carvedilol.

• Vasodilatory beta blockers used in patients with reduced LVEF include:
  • Carvedilol 2 The FDA label does not mention other vasodilatory beta blockers.

From the Research

Vasodilatory Beta Blockers

The vasodilatory beta blockers used in patients with reduced Left Ventricular Ejection Fraction (LVEF) include:

• Carvedilol 3, 4, 5, 6
• Sustained-release metoprolol succinate 3, 4
• Bisoprolol 3, 4, 6
• Nebivolol 6

Characteristics of Vasodilatory Beta Blockers

These beta blockers have been shown to:

• Improve cardiac mortality and morbidity in patients with HFref 4
• Be tolerable in patients with HFref 4
• Improve left ventricular ejection fraction (LVEF) in patients with heart failure 6
• Reduce rehospitalization rates in vulnerable heart failure patients 5

Clinical Use

The use of vasodilatory beta blockers in patients with reduced LVEF is supported by various studies, including:

• The CIBS-II trial (bisoprolol) 4
• The MERIT-HF trial (metoprolol succinate) 4
• The Copernicus trial (carvedilol) 4
• The study by Packer et al. (carvedilol) 6