What are the beta blockers (BB) recommended in heart failure (HF)?

Beta Blockers Recommended in Heart Failure

The three beta blockers proven to reduce mortality in heart failure with reduced ejection fraction (HFrEF) are bisoprolol, carvedilol, and sustained-release metoprolol succinate. 1

Evidence-Based Beta Blocker Selection in HFrEF

• Beta blockers are a cornerstone of therapy for patients with HFrEF and are recommended in addition to ACE inhibitors/ARBs/ARNIs to reduce the risk of hospitalization and death 1
• Only three specific beta blockers have demonstrated mortality benefits in clinical trials for HFrEF: bisoprolol, carvedilol, and sustained-release metoprolol succinate 1
• These beta blockers should be prescribed for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated 1

Dosing Considerations

• Beta blockers should be initiated at low doses and gradually titrated to target doses or maximally tolerated doses 1
• Target doses for the recommended beta blockers in HFrEF:
  • Bisoprolol: 10 mg once daily 1
  • Carvedilol: 25 mg twice daily (50 mg twice daily for patients >85 kg) 1
  • Metoprolol succinate: 200 mg once daily 1
• Achieving at least 50% of target dose is associated with improved outcomes 1, 2

Comparative Effectiveness

• Carvedilol may offer additional benefits compared to metoprolol due to its alpha-1 blocking properties in addition to beta-1 and beta-2 blockade 3, 4
• A large VA study showed improved survival with carvedilol compared to metoprolol succinate in patients with HFrEF (55.6% vs 49.2% six-year survival) 4
• Patients who remain symptomatic despite optimal doses of metoprolol may benefit from switching to carvedilol 3

Beta Blockers in Heart Failure with Mildly Reduced EF (HFmrEF)

• Beta blockers may be considered for patients with HFmrEF (LVEF 41-49%), particularly for those with LVEF on the lower end of this spectrum 1
• This recommendation carries a lower level of evidence (Class 2b, Level B-NR) compared to their use in HFrEF 1

Special Considerations and Contraindications

• Beta blockers should be initiated only when patients are stable (not during acute decompensation) 5
• Caution is needed in patients with:
  • Bronchospastic disease (bisoprolol may be preferred due to relative beta-1 selectivity) 6, 7
  • Diabetes (carvedilol and nebivolol may offer metabolic advantages) 7
  • Peripheral arterial disease (nebivolol may be preferred) 7
• Absolute contraindications include:
  • Severe bradycardia or high-degree AV block without pacemaker 6
  • Decompensated heart failure requiring inotropic support 8

Implementation in Clinical Practice

• Despite strong evidence supporting their use, beta blockers remain underutilized in HFrEF patients 1, 9
• Common barriers include concerns about adverse effects and worsening heart failure symptoms 9
• For patients hospitalized with acute decompensated heart failure who are already on beta blockers, therapy should be continued when possible, as withdrawal is associated with increased mortality 5
• Beta blockers should be initiated before discharge in stabilized patients who were not previously on them 5

Beta blockers are a critical component of guideline-directed medical therapy for heart failure, with clear evidence showing mortality benefits when using bisoprolol, carvedilol, or sustained-release metoprolol succinate specifically.