What is the recommended dose of bisoprolol (beta-blocker) in patients with heart failure?

Bisoprolol Dosing in Heart Failure

The recommended dosing protocol for bisoprolol in heart failure is to start at 1.25 mg once daily and gradually titrate to a target dose of 10 mg once daily, with dose doubling at not less than 2-week intervals. 1, 2

Initial Dosing and Titration

• Starting dose: 1.25 mg once daily 1, 2
• Titration schedule: Double dose at not less than 2-week intervals 1, 2
• Target dose: 10 mg once daily 1, 2

Dose Adjustment Considerations

• For patients with renal dysfunction (creatinine clearance <40 mL/min) or hepatic impairment, start with 1.25 mg daily and use caution during titration 3
• Elderly patients do not require dose adjustment unless they have significant renal or hepatic dysfunction 3
• Aim for the target dose (10 mg) or the highest tolerated dose 1
• Remember that some beta-blocker is better than no beta-blocker 1

Monitoring During Titration

• Monitor heart rate, blood pressure, and clinical status (symptoms, signs of congestion, body weight) 1, 2
• Check blood chemistry 12 weeks after initiation and 12 weeks after final dose titration 1
• A specialist heart failure nurse may assist with patient education, follow-up, and dose titration 1

Managing Common Problems During Titration

Worsening Heart Failure Symptoms

• If increasing congestion occurs: double diuretic dose and/or halve bisoprolol dose 1
• If marked fatigue develops: halve bisoprolol dose 1
• If serious deterioration occurs: halve dose or stop treatment (rarely necessary) 1

Bradycardia

• If heart rate <50 beats/min with worsening symptoms: halve bisoprolol dose 1
• Review need for other heart rate-slowing drugs (digoxin, amiodarone, diltiazem) 1
• Arrange ECG to exclude heart block 1

Hypotension

• Asymptomatic low blood pressure usually doesn't require therapy change 1
• For symptomatic hypotension: reconsider need for nitrates, calcium channel blockers and other vasodilators 1
• If no congestion, consider reducing diuretic dose 1

Clinical Evidence and Outcomes

• The CIBIS-II trial demonstrated that bisoprolol reduced all-cause mortality by 34% compared to placebo in heart failure patients 1
• Even patients who can only tolerate lower doses of bisoprolol (1.25-3.75 mg/day) still derive significant mortality benefit 4
• Studies show that 63% of patients can achieve the maximum targeted dose with proper titration 5
• The American College of Cardiology/American Heart Association recommends achieving at least 50% of the target dose (5 mg for bisoprolol) 1

Important Cautions

• Do not stop bisoprolol suddenly unless absolutely necessary due to risk of "rebound" myocardial ischemia/infarction and arrhythmias 1
• Patients should be advised to report deterioration but not to stop therapy without consulting their physician 1
• Patients should weigh themselves daily and increase diuretic dose if weight increases persistently by 1.5-2.0 kg over 2 days 1

Bisoprolol, along with carvedilol and metoprolol succinate, is one of the three beta-blockers proven to reduce mortality in heart failure patients with reduced ejection fraction, and should be titrated to the target dose whenever possible to maximize clinical benefits.