Recommended Beta Blocker Agents and Dosages for Beta Blocker Therapy
For patients requiring beta blocker therapy, the recommended agents are bisoprolol, carvedilol, and metoprolol succinate (extended-release), with specific starting and target doses based on the indication. 1
Heart Failure with Reduced Ejection Fraction (HFrEF)
Recommended Beta Blockers and Dosing for HFrEF
- Bisoprolol: Start at 1.25 mg once daily, target dose 10 mg once daily 1
- Carvedilol: Start at 3.125 mg twice daily, target dose 25-50 mg twice daily 1
- Metoprolol succinate extended release: Start at 12.5-25 mg once daily, target dose 200 mg once daily 1
Administration Guidelines for HFrEF
- Start with low doses and double the dose at intervals of not less than 2 weeks 1
- Aim for target doses used in clinical trials or the highest tolerated dose 1
- Monitor heart rate, blood pressure, clinical status, and signs of congestion 1
- Check blood chemistry 12 weeks after initiation and 12 weeks after final dose titration 1
- Even lower doses provide benefit if target doses cannot be tolerated 1
Cautions and Special Considerations
- Seek specialist advice for patients with severe (NYHA class IV) heart failure 1
- Use caution in patients with recent (within 4 weeks) heart failure exacerbation 1
- Avoid in patients with heart block or heart rate <60/min 1
- Use caution in patients with signs of congestion (raised jugular venous pressure, ascites, marked peripheral edema) 1
Hypertension
Recommended Beta Blockers and Dosing for Hypertension
- Atenolol: Start at 25-50 mg once daily, target dose 50-100 mg once daily 1, 2
- Metoprolol tartrate: 100-200 mg daily in divided doses 1
- Bisoprolol: 2.5-10 mg once daily 1
- Carvedilol: 12.5-50 mg daily in divided doses 1
- Nebivolol: 5-40 mg once daily 1
Special Considerations for Hypertension
- Beta blockers are not recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure 1
- For elderly patients or those with renal impairment, lower starting doses are recommended 2
- For patients with creatinine clearance 15-35 mL/min, maximum atenolol dose is 50 mg daily 2
- For patients with creatinine clearance <15 mL/min, maximum atenolol dose is 25 mg daily 2
Post-Myocardial Infarction
Recommended Beta Blockers for Post-MI
- Carvedilol: Start at 6.25 mg twice daily, titrate to 25 mg twice daily as tolerated 3
- Metoprolol succinate: Follow heart failure dosing regimen 1
- Atenolol: After IV administration (if tolerated), 50 mg orally followed by another 50 mg 12 hours later, then 100 mg once daily or 50 mg twice daily 2
Clinical Pearls and Pitfalls
Important Considerations
- Beta blockers significantly reduce mortality in heart failure (34% relative risk reduction) 1, 4
- Only three beta blockers (bisoprolol, carvedilol, metoprolol succinate) have demonstrated mortality reduction in heart failure - this is not a class effect 1, 5
- In practice, most patients receive less than half the recommended target doses 4
- Some beta blocker is better than no beta blocker when target doses cannot be achieved 1
Managing Common Adverse Effects
- For worsening congestion: double the dose of diuretic and/or halve the dose of beta blocker 1
- For marked fatigue or bradycardia: halve the dose of beta blocker 1
- For heart rate <50 beats/min with worsening symptoms: halve dose or stop beta blocker if severe deterioration 1
- For patients on beta blockers requiring emergency treatment for anaphylaxis: consider glucagon (1-5 mg IV) 1
Special Populations
- In patients with diabetes, carvedilol has been shown not to adversely affect glycemic control 3
- For patients with bronchospastic airway disease requiring a beta blocker, cardioselective agents (bisoprolol, metoprolol) are preferred 1
- Avoid abrupt cessation of beta blocker therapy, which can lead to rebound hypertension or worsening ischemia 1, 2
By following these evidence-based recommendations for beta blocker selection and dosing, clinicians can optimize outcomes while minimizing adverse effects in patients requiring beta blocker therapy.