What are the guidelines for choosing a beta-blocker (beta-adrenergic blocking agent) to prescribe?

Beta-Blocker Selection Algorithm

For heart failure with reduced ejection fraction (HFrEF), prescribe one of only three beta-blockers with proven mortality reduction: bisoprolol, carvedilol, or metoprolol succinate extended-release—no other beta-blockers should be used for this indication. 1, 2

Primary Decision Point: Clinical Indication

Heart Failure with Reduced Ejection Fraction (LVEF ≤40%)

Choose from these three agents ONLY (Class I, Level A evidence):

• Bisoprolol: Start 1.25 mg once daily, target 10 mg once daily 1, 2
• Carvedilol: Start 3.125 mg twice daily, target 25-50 mg twice daily (or carvedilol CR 80 mg once daily) 1, 2
• Metoprolol succinate (extended-release): Start 12.5-25 mg once daily, target 200 mg once daily 1, 2

Critical distinction: Metoprolol tartrate (immediate-release) has NOT demonstrated mortality reduction and should NOT be used for heart failure 1, 2. This is not a class effect—bucindolol failed to show uniform effectiveness, and nebivolol did not affect mortality alone 1.

Selecting Among the Three Evidence-Based Agents

Carvedilol may be preferred when:

• Patient has HFrEF requiring both alpha- and beta-blockade 1, 2
• Combined vasodilation is desired (blocks alpha-1, beta-1, and beta-2 receptors) 1

Bisoprolol or metoprolol succinate may be preferred when:

• Patient has bronchospastic airway disease requiring a beta-blocker (these are beta-1 selective) 1, 2
• Once-daily dosing compliance is a concern (bisoprolol and metoprolol succinate are once daily vs. carvedilol twice daily) 2

All three agents demonstrated 34% relative risk reduction in mortality 2, 3, so choice among them can be based on dosing convenience, side effect profile, and patient-specific factors 1.

Post-Myocardial Infarction

Proven agents with mortality benefit:

• Metoprolol succinate (follow HFrEF dosing if LV dysfunction present) 1, 2
• Propranolol, timolol (if no LV dysfunction) 4, 5
• Carvedilol (if LV dysfunction present) 4

Key principle: Lipophilic beta-blockers (metoprolol, propranolol, timolol, bisoprolol, carvedilol) reduce sudden cardiac death more effectively than hydrophilic agents (atenolol, sotalol) 6. Sotalol reduced reinfarction but had no effect on sudden death 6.

Hypertension

Beta-blockers are NOT first-line agents unless patient has ischemic heart disease or heart failure 1, 2. When indicated:

• Atenolol: 25-100 mg once daily 1
• Metoprolol tartrate: 100-200 mg daily in divided doses 1
• Bisoprolol: 2.5-10 mg once daily 1
• Carvedilol: 12.5-50 mg daily in divided doses 1
• Nebivolol: 5-40 mg once daily 1

For hypertension with concurrent HFrEF: Use HFrEF dosing regimen with one of the three proven agents 2.

Dosing Strategy for HFrEF (All Three Agents)

Start low, go slow, aim high:

1. Initiate at very low doses in stable, compensated patients already on diuretics and ACE inhibitor/ARB 1, 2
2. Double the dose every 2 weeks if previous dose well tolerated 2
3. Target the trial-proven doses: These doses achieved mortality reduction in clinical trials 1, 2
4. Minimum effective dose: Aim for at least 50% of target dose if full target cannot be tolerated 1, 2

Target doses:

• Bisoprolol: 10 mg once daily 2
• Carvedilol: 25-50 mg twice daily (or 80 mg CR once daily) 2
• Metoprolol succinate: 200 mg once daily 2, 3

Critical Contraindications and Precautions

Absolute contraindications:

• Current or recent (within 4 weeks) heart failure exacerbation requiring hospitalization 2
• Second- or third-degree heart block without pacemaker 1, 2
• Sick sinus syndrome without pacemaker 1, 2
• Active asthma or severe reactive airway disease 1
• Sinus bradycardia <50 bpm 1

Relative contraindications (use cautiously):

• Reactive airway disease with asymptomatic periods (consider beta-1 selective agents) 1
• Asymptomatic bradycardia 1

Managing Adverse Effects During Titration

For worsening congestion:

1. First: Double diuretic dose 2
2. Second: Halve beta-blocker dose only if increasing diuretic fails 2

For symptomatic hypotension:

1. First: Reduce or eliminate vasodilators (nitrates, calcium channel blockers) 2
2. Second: Reduce diuretic dose if no congestion present 2
3. Third: Halve beta-blocker dose or slow titration 2
4. Last resort: Seek specialist advice before discontinuation 2

For marked fatigue or bradycardia <50 bpm with worsening symptoms:

• Halve beta-blocker dose 2

For severe deterioration with heart rate <50 bpm:

• Halve dose or stop beta-blocker temporarily 2

Essential Clinical Pitfalls to Avoid

Never use metoprolol tartrate for heart failure—only metoprolol succinate extended-release has mortality data 1, 2. This is the single most common prescribing error.

Never abruptly discontinue beta-blockers—risk of rebound myocardial ischemia, infarction, and arrhythmias 1, 2. Always taper if discontinuation necessary.

Do not extrapolate benefits across all beta-blockers—mortality reduction is NOT a class effect 1, 4. Only the three agents listed have proven survival benefit in HFrEF.

Do not delay beta-blocker initiation until symptoms worsen—start as soon as HFrEF is diagnosed, even if symptoms are mild 1.

Do not require high-dose ACE inhibitor before starting beta-blocker—adding a beta-blocker to low-dose ACE inhibitor produces greater mortality reduction than increasing ACE inhibitor dose 1.

Some beta-blocker is better than no beta-blocker—if target doses cannot be achieved, maintain the highest tolerated dose rather than discontinuing 2.

Monitoring Requirements

During titration (every 2 weeks):

• Heart rate and blood pressure 2
• Signs of congestion and body weight 2
• Clinical status and symptoms 2

After achieving maintenance dose:

• Blood chemistry at 12 weeks after initiation and 12 weeks after final dose 2
• Ongoing monitoring every 6 months 1