What are the typical doses of carvedilol (beta blocker), bisoprolol (beta blocker), and metoprolol (beta blocker) for patients with heart failure and hypertension?

Beta-Blocker Dosing for Heart Failure and Hypertension

For heart failure with reduced ejection fraction (HFrEF), use bisoprolol 1.25-10 mg once daily, carvedilol 3.125-50 mg twice daily (6.25-100 mg total daily), or metoprolol succinate extended-release 12.5-200 mg once daily—start low and double the dose every 2 weeks as tolerated, aiming for target doses proven to reduce mortality by 34%. 1

Carvedilol Dosing

Heart Failure with Reduced Ejection Fraction

• Starting dose: 3.125 mg twice daily 1, 2, 3
• Titration schedule: Double every 1-2 weeks if tolerated: 3.125 mg → 6.25 mg → 12.5 mg → 25 mg twice daily 1, 2, 4
• Target dose: 25 mg twice daily (50 mg total daily dose) for patients <85 kg; may increase to 50 mg twice daily for patients >85 kg 1, 4, 3
• Maximum dose: 50 mg twice daily (100 mg total daily) 4
• Carvedilol should be taken with food to reduce orthostatic effects 3

Hypertension

• Starting dose: 6.25 mg twice daily 2, 3
• Titration: Increase to 12.5 mg twice daily after 7-14 days if tolerated, then to 25 mg twice daily if needed 2, 3
• Maximum dose: 25 mg twice daily (50 mg total daily) 2, 3
• Beta-blockers are not first-line for hypertension unless the patient has ischemic heart disease or heart failure 1, 2

Post-Myocardial Infarction

• Starting dose: 6.25 mg twice daily (or 3.125 mg twice daily if hemodynamically unstable) 3
• Titration: Increase after 3-10 days to 12.5 mg twice daily, then to target of 25 mg twice daily 3
• Start only after hemodynamic stability and fluid retention minimized 3

Metoprolol Succinate Extended-Release Dosing

Heart Failure with Reduced Ejection Fraction

• Starting dose: 12.5-25 mg once daily depending on severity (use 12.5 mg for NYHA Class III-IV) 1, 5
• Titration schedule: Double every 2 weeks as tolerated: 12.5 mg → 25 mg → 50 mg → 100 mg → 200 mg once daily 1, 5
• Target dose: 200 mg once daily 1, 5
• This target dose achieved 34% reduction in all-cause mortality, 38% reduction in cardiovascular mortality, and 35% reduction in heart failure hospitalization 1
• Only metoprolol succinate extended-release (not metoprolol tartrate) has proven mortality benefit in heart failure 1

Hypertension

• Starting dose: 25-100 mg once daily 5
• Titration: Increase at weekly intervals until optimal blood pressure control 5
• Maximum studied dose: 400 mg daily 5

Angina

• Starting dose: 100 mg once daily 5
• Titration: Increase gradually at weekly intervals as needed 5
• Maximum studied dose: 400 mg daily 5

Bisoprolol Dosing

Heart Failure with Reduced Ejection Fraction

• Starting dose: 1.25 mg once daily 1
• Titration schedule: Double every 2-4 weeks as tolerated: 1.25 mg → 2.5 mg → 5 mg → 10 mg once daily 1
• Target dose: 10 mg once daily 1
• Bisoprolol offers once-daily dosing with more consistent beta-blockade compared to twice-daily agents 1

Hypertension

• Starting dose: 2.5 mg once daily 1
• Target dose: 2.5-10 mg once daily 1
• Not recommended as first-line unless patient has ischemic heart disease or heart failure 1

Critical Monitoring and Management Principles

During Titration

• Monitor heart rate, blood pressure, clinical status, and signs of congestion at each dose escalation 1
• Check blood chemistry 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 Adverse Effects

For worsening congestion:

• First: Double the diuretic dose 1
• Second: Halve the beta-blocker dose only if increasing diuretic fails 1

For symptomatic hypotension:

• First: Reduce or eliminate vasodilators (nitrates, calcium channel blockers) 1
• Second: Reduce diuretic dose if no congestion present 1
• Third: Halve beta-blocker dose only if above measures fail 1
• Asymptomatic low blood pressure requires no dose adjustment 1

For marked fatigue or bradycardia:

• Halve the beta-blocker dose 1
• If heart rate <50 bpm with worsening symptoms, halve dose or stop if severe deterioration 1

Essential Clinical Pearls

Mortality Benefits

• All three beta-blockers (bisoprolol, carvedilol, metoprolol succinate) reduce mortality by approximately 34% in HFrEF 1
• This is NOT a class effect—only these three specific agents have proven mortality reduction 1
• Even if target doses cannot be achieved, aim for at least 50% of target dose to obtain mortality benefits 1, 2
• Some beta-blocker is better than no beta-blocker 1

Common Pitfalls to Avoid

• Underdosing is the most common error—many clinicians maintain patients on suboptimal doses due to fear of side effects or clinical inertia 1, 2
• Never abruptly discontinue beta-blockers—this can precipitate rebound hypertension, myocardial ischemia, infarction, and arrhythmias 1, 2
• Do not initiate beta-blockers during acute decompensated heart failure or within 4 weeks of hospitalization for heart failure exacerbation 1
• Avoid combining carvedilol with dobutamine in decompensated patients—selective beta-1 blockade at low carvedilol doses can paradoxically worsen hypotension 1

Contraindications

• Severe hepatic impairment (carvedilol) 2, 3
• Asthma with positive bronchoreactivity 1, 2
• Second- or third-degree heart block without pacemaker 1, 2
• Sick sinus syndrome without pacemaker 1, 2
• Sinus bradycardia <50 bpm 1
• Current or recent (within 4 weeks) decompensated heart failure requiring hospitalization 1, 2

Special Considerations

• Carvedilol has combined alpha- and beta-blocking properties, providing additional vasodilation, which may be beneficial but also increases risk of hypotension 1, 2
• For patients with bronchospastic disease requiring a beta-blocker, use cardioselective agents (bisoprolol or metoprolol) 1
• Switching from carvedilol to bisoprolol may help patients who cannot tolerate carvedilol due to dizziness or hypotension 6
• For patients on beta-blockers requiring emergency treatment for anaphylaxis, consider glucagon 1-5 mg IV 1