What are the recommended beta blockers (beta-adrenergic blocking agents) and dosages for patients with cardiovascular conditions such as heart failure, hypertension, or arrhythmias?

Recommended Beta Blockers and Dosages for Cardiovascular Conditions

For patients with cardiovascular conditions such as heart failure, hypertension, or arrhythmias, the three beta blockers proven to reduce mortality are bisoprolol, carvedilol, and sustained-release metoprolol succinate, with specific dosing regimens for each condition. 1, 2

Heart Failure with Reduced Ejection Fraction (HFrEF)

First-line Beta Blockers and Dosing

• Metoprolol succinate (extended-release) 1, 2

  • Starting dose: 12.5-25 mg once daily
  • Target dose: 200 mg once daily
  • Titration: Gradual increase at 2-week intervals

• Carvedilol 1, 2, 3

  • Starting dose: 3.125 mg twice daily
  • Target dose: 25 mg twice daily (50 mg twice daily for patients >85 kg)
  • Titration: Double dose every 2 weeks if tolerated

• Bisoprolol 2, 4

  • Starting dose: 1.25 mg once daily
  • Target dose: 10 mg once daily
  • Titration: Double dose at minimum 2-week intervals

Implementation Strategy

1. Start at low doses in stable patients
2. Gradually titrate upward to target doses (aim for approximately 70% of maximum trial doses if full doses not tolerated) 4
3. Monitor for bradycardia, hypotension, and worsening heart failure during titration
4. Continue beta blockers even if LVEF improves to >40% 2

Hypertension

Recommended Agents and Dosing

• Metoprolol 2

  • Dose: 50-200 mg twice daily (immediate release) or once daily (extended-release)
  • Particularly beneficial in patients with CAD, tachyarrhythmias, and post-MI

• Carvedilol 3

  • Dose: 6.25-25 mg twice daily
  • Particularly useful in patients with concomitant heart failure or diabetes

• Atenolol 1

  • Dose: 50-200 mg daily
  • Simple once-daily dosing

• Propranolol 1

  • Dose: 20-80 mg twice daily
  • Non-selective agent, useful for additional indications like migraine

Selection Considerations

• Cardioselective agents (metoprolol, bisoprolol, atenolol) preferred in patients with bronchospastic disease 2
• Carvedilol has additional alpha-blocking properties, beneficial in patients with diabetes 3
• Consider once-daily formulations to improve adherence

Post-Myocardial Infarction

Recommended Agents

• Carvedilol 3

  • Shown to reduce mortality by 23% post-MI
  • Reduces risk of recurrent MI by 40%
  • Target dose: 25 mg twice daily

• Metoprolol succinate 2

  • Target dose: 200 mg once daily
  • Particularly beneficial in post-MI patients with tachycardia

Arrhythmias

Recommended Agents

• Metoprolol 1, 2

  • For rate control in atrial fibrillation: 25-100 mg twice daily
  • For ventricular arrhythmias: 50-200 mg daily

• Atenolol 1

  • For supraventricular tachycardias: 50-100 mg daily

Contraindications and Cautions

Absolute Contraindications 1

• Cardiogenic shock
• Severe bradycardia (heart rate <50 bpm)
• Advanced heart block without pacemaker
• Severe hypotension (systolic BP <90 mmHg)
• Decompensated heart failure

Relative Contraindications

• Asthma or severe COPD with bronchospasm (use cardioselective agents with caution if necessary) 2
• Severe peripheral vascular disease
• Poorly controlled diabetes (monitor closely)

Monitoring Recommendations

• Heart rate and blood pressure at each dose titration
• Symptoms of worsening heart failure (weight gain, dyspnea, edema)
• Renal function and electrolytes when used with ACE inhibitors/ARBs/MRAs 2
• Consider ECG monitoring in patients with conduction abnormalities

Integration with Other Therapies

Beta blockers should be used as part of comprehensive therapy including:

• ACE inhibitors/ARBs/ARNi
• Mineralocorticoid receptor antagonists (in HFrEF)
• SGLT2 inhibitors (in HFrEF and select HFmrEF patients) 1
• Diuretics as needed for congestion

Key Evidence on Outcomes

• Beta blockers reduce all-cause mortality by 34-35% in patients with systolic heart failure 2, 5
• Carvedilol reduces post-MI mortality by 23% and recurrent MI risk by 40% 3
• Beta blockers improve quality of life and reduce hospitalizations in heart failure patients 6
• Higher doses correlate with better clinical outcomes, emphasizing the importance of dose titration 6

Beta blockers remain underutilized despite strong evidence supporting their mortality benefit across cardiovascular conditions 7. Appropriate selection and dosing of these agents should be prioritized in cardiovascular care.