What is the recommended dosage and usage of Bisoprolol (beta-blocker) for patients with heart failure or high blood pressure?

Bisoprolol Dosing and Usage

For heart failure with reduced ejection fraction, start bisoprolol at 1.25 mg once daily and titrate every 1-2 weeks to the target dose of 10 mg once daily; for hypertension, start at 5 mg once daily (or 2.5 mg in patients with bronchospastic disease or hepatic/renal impairment) and increase to 10-20 mg as needed. 1, 2, 3

Heart Failure with Reduced Ejection Fraction (HFrEF)

Starting Dose and Titration

• Begin at 1.25 mg once daily in patients with stable heart failure already on ACE inhibitors and diuretics 1, 2
• Double the dose every 1-2 weeks as tolerated, following this schedule: 1.25 mg → 2.5 mg → 3.75 mg → 5 mg → 7.5 mg → 10 mg 1, 2
• Target dose is 10 mg once daily, which demonstrated a 34% reduction in all-cause mortality in the CIBIS-II trial 4, 1, 2

Critical Prerequisites

• Patients must be in relatively stable condition without need for intravenous inotropic therapy 2
• Background therapy with ACE inhibitors is required unless contraindicated 2
• Bisoprolol is contraindicated in current or recent (within 4 weeks) exacerbation requiring hospitalization 1

Mortality Benefits

• Treatment with bisoprolol at target doses reduces all-cause mortality by 34% (RR 0.66,95% CI 0.54-0.81) 4
• Sudden death is reduced by 44% (RR 0.56,95% CI 0.39-0.80) 4
• Number needed to treat is 23 patients for 1 year to prevent 1 death 4
• Even lower doses provide mortality benefit if target cannot be tolerated—some bisoprolol is better than no bisoprolol 1, 5

Monitoring During Titration

• Check heart rate, blood pressure, clinical status, and signs of congestion at each dose increase 1, 2
• Monitor blood chemistry at 12 weeks after initiation and 12 weeks after final dose titration 1
• Patients should weigh themselves daily and increase diuretic if weight increases by 1.5-2.0 kg over 2 days 1

Managing Complications During Titration

For worsening congestion:

• First double the diuretic dose 1
• If inadequate response, halve the bisoprolol dose 1

For marked fatigue or bradycardia:

• Halve the bisoprolol dose 1

For heart rate <50 bpm with worsening symptoms:

• Halve the dose or stop bisoprolol if severe deterioration occurs 1

For symptomatic hypotension:

• Adjust other medications (ACE inhibitors, diuretics) before reducing bisoprolol 1, 2

Hypertension

Standard Dosing

• Starting dose is 5 mg once daily for most patients 3
• If 5 mg provides inadequate blood pressure control, increase to 10 mg, then to 20 mg once daily if necessary 3
• For hypertension with concurrent heart failure or ischemic heart disease, follow the heart failure dosing regimen (starting at 1.25 mg) 1

Special Populations Requiring Lower Starting Dose (2.5 mg)

• Patients with bronchospastic disease 3
• Hepatic impairment (hepatitis or cirrhosis) 3
• Renal dysfunction (creatinine clearance <40 mL/min) 3
• Use caution with dose titration in these populations 3

Important Caveat

• Beta-blockers are not recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure 1

Absolute Contraindications

• Asthma or severe bronchospastic disease 2
• Second or third-degree AV block without pacemaker 2
• Sick sinus syndrome without permanent pacemaker 1
• Sinus bradycardia <50 bpm 1
• Symptomatic bradycardia or hypotension 2
• Current decompensated heart failure (NYHA class IV) or recent exacerbation within 4 weeks 1

Critical Safety Considerations

Dialysis Patients

• Bisoprolol is not dialyzable, so dose replacement is not necessary in patients undergoing dialysis 3

Elderly Patients

• No dose adjustment needed unless significant renal or hepatic dysfunction is present 3

Abrupt Discontinuation

• Never stop bisoprolol suddenly unless absolutely necessary—risk of rebound ischemia, infarction, and arrhythmias 1
• Treatment withdrawal is associated with a 2.13-fold increase in mortality risk (95% CI 1.43-3.17) 5

Dose-Response Relationship

• All tolerated dose levels reduce mortality: low dose (1.25-3.75 mg) RR 0.66, moderate dose (5-7.5 mg) RR 0.33, high dose (10 mg) RR 0.59 5
• Efforts should be made to maintain bisoprolol therapy at the highest tolerated dose rather than discontinuing 5

Cardioselectivity Advantage

• Bisoprolol is highly selective for beta-1 receptors, making it preferred for patients with bronchospastic airway disease who require a beta-blocker 1