What are the alternatives to Coreg (carvedilol) for managing hypertension and heart failure?

Alternatives to Carvedilol for Hypertension and Heart Failure

For patients requiring an alternative to carvedilol, the preferred beta-blockers with proven mortality benefit in heart failure are metoprolol succinate, bisoprolol, or nebivolol, while for hypertension alone, any first-line antihypertensive class (ACE inhibitors, ARBs, thiazide diuretics, or calcium channel blockers) is appropriate. 1

Beta-Blocker Alternatives for Heart Failure with Reduced Ejection Fraction (HFrEF)

If you need to switch from carvedilol specifically for heart failure management, only four beta-blockers have demonstrated mortality reduction in randomized controlled trials:

Evidence-Based Beta-Blocker Options:

• Metoprolol succinate (extended-release): 50-200 mg once daily, proven to reduce mortality in the MERIT-HF trial 1

  • Note: Metoprolol tartrate is NOT the formulation proven effective in heart failure 1
  • The COMET trial showed carvedilol provided 17% greater mortality reduction compared to metoprolol tartrate, though this comparison used the immediate-release formulation 1, 2

• Bisoprolol: 2.5-10 mg once daily, demonstrated 32% reduction in all-cause mortality and 44% reduction in sudden death in the CIBIS-II trial 1

• Nebivolol: 5-40 mg once daily, a β1-selective blocker with vasodilating properties that significantly reduced mortality/cardiovascular hospitalizations in elderly patients (≥70 years) in the SENIORS trial 1

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

Non-Beta-Blocker Alternatives for Heart Failure

For patients with HFrEF who cannot tolerate any beta-blocker, guideline-directed medical therapy includes:

ACE Inhibitors or ARBs:

• These are foundational therapy for HFrEF and also lower blood pressure effectively 1
• Examples: lisinopril, enalapril, losartan, valsartan 1

Mineralocorticoid Receptor Antagonists:

• Spironolactone: 25-100 mg once daily, reduced mortality by 30% in RALES trial 1
• Eplerenone: 50-100 mg once or twice daily, reduced mortality by 15% post-MI in EPHESUS and 37% reduction in cardiovascular death/HF hospitalization in EMPHASIS 1
• These agents are particularly beneficial in resistant hypertension and provide additional blood pressure lowering 1

Diuretics:

• Thiazide-type diuretics (chlorthalidone, hydrochlorothiazide): First-line for hypertension, effective in reducing HF incidence 1
• Loop diuretics (furosemide 20-80 mg twice daily, torsemide 5-10 mg once daily): Preferred in symptomatic HF with volume overload 1

Alternatives for Hypertension Without Heart Failure

If the indication is purely hypertension management without heart failure, the 2017 ACC/AHA guidelines recommend these first-line options:

Primary Antihypertensive Agents:

• ACE Inhibitors: Lisinopril 10-40 mg, enalapril 5-40 mg daily 1
• ARBs: Losartan 50-100 mg, valsartan 80-320 mg daily 1
• Thiazide-type diuretics: Chlorthalidone 12.5-25 mg, hydrochlorothiazide 25-50 mg daily 1
• Calcium Channel Blockers (dihydropyridines): Amlodipine 2.5-10 mg, nifedipine LA 30-90 mg daily 1

Critical warning: Nondihydropyridine calcium channel blockers (diltiazem, verapamil) should be avoided in patients with HFrEF due to myocardial depressant activity and worse outcomes 1

Special Considerations for Post-Myocardial Infarction

For patients with recent MI and left ventricular dysfunction (ejection fraction ≤40%), carvedilol reduced all-cause mortality by 23% and fatal/non-fatal MI by 40% in the CAPRICORN trial 3. Alternative beta-blockers (metoprolol succinate, bisoprolol) are appropriate substitutes in this population 1.

Target Blood Pressure Goals

• With HFrEF: Target systolic BP <130 mmHg, though successful trials achieved 110-130 mmHg 1, 2
• General hypertension: <130/80 mmHg per 2017 ACC/AHA guidelines 1

Combination Therapy Approach

When a single agent is insufficient, the evidence supports:

• ACE inhibitor/ARB + thiazide diuretic: Most common and effective combination 1
• ACE inhibitor/ARB + calcium channel blocker: Alternative combination 1
• Triple therapy: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic for resistant hypertension 1

For African American patients with advanced HF (NYHA class III-IV): Add hydralazine 100-200 mg plus isosorbide dinitrate to standard therapy, which reduced mortality by 40% in the A-HeFT trial 1