Bisoprolol Dosage and Frequency in Compensated and Decompensated Heart Failure
For heart failure patients, bisoprolol should be started at 1.25 mg once daily, with dose doubling at intervals of not less than 2 weeks, aiming for a target dose of 10 mg once daily or the highest tolerated dose. 1, 2
Dosing in Compensated Heart Failure
- Start with 1.25 mg once daily in stable patients with compensated heart failure 1, 2
- Double the dose at not less than 2-week intervals (1.25 → 2.5 → 5 → 10 mg once daily) 1, 2
- Aim for the target dose of 10 mg once daily, which has demonstrated mortality benefits in clinical trials 1, 2
- If target dose cannot be achieved, maintain the highest tolerated dose - some bisoprolol is better than no bisoprolol 1, 2
- Monitor heart rate, blood pressure, clinical status, and signs of congestion during titration 1, 2
- Check blood chemistry 12 weeks after initiation and 12 weeks after final dose titration 1
Dosing in Decompensated Heart Failure
- Bisoprolol is contraindicated in current or recent (within 4 weeks) exacerbation of heart failure requiring hospitalization 1, 2
- For patients with severe (NYHA class IV) or decompensated heart failure, specialist advice should be sought before initiating bisoprolol 1, 2
- If a patient on bisoprolol develops decompensation:
- For increasing congestion: double the dose of diuretic and/or halve the dose of bisoprolol if increasing diuretic does not work 1, 2
- For marked fatigue or bradycardia: halve the dose of bisoprolol 1
- For serious deterioration: halve the dose or stop treatment (rarely necessary) and seek specialist advice 1
Monitoring Parameters
- Heart rate (if <50 beats/min with worsening symptoms, halve dose or stop bisoprolol) 1, 2
- Blood pressure (symptomatic hypotension may require adjustment of other medications) 1
- Clinical status, especially signs of congestion and body weight 1
- Patients should weigh themselves daily and increase diuretic dose if weight increases persistently (2 days) by 1.5-2.0 kg 1
Special Considerations
- In patients with renal dysfunction (creatinine clearance <40 mL/min) or hepatic impairment, the initial daily dose should be 2.5 mg with cautious titration 3
- Even lower doses of bisoprolol provide mortality benefit compared to no treatment, as demonstrated in the CIBIS II study 4
- Withdrawal of bisoprolol is associated with increased mortality risk; efforts should be made to maintain therapy based on individual tolerability 4
- Bisoprolol should not be stopped suddenly unless absolutely necessary due to risk of rebound ischemia/infarction and arrhythmias 1
Efficacy Considerations
- Studies show that 63% of patients can achieve the maximum target dose of 10 mg daily in outpatient settings 5
- Even patients who can only tolerate lower doses (1.25-3.75 mg/day) still derive significant mortality benefits 4
- Improvements in left ventricular systolic function and remodeling are greater with higher doses (≥3.75 mg/day) compared to lower doses 6
- Wide variability in serum concentrations exists at the same daily dose, with patients having reduced cardiac function showing higher concentration-to-dose ratios 7