Alternative Beta Blockers to Metoprolol
For heart failure with reduced ejection fraction, bisoprolol and carvedilol are the evidence-based alternatives to metoprolol, while for hypertension, atenolol, bisoprolol, carvedilol, and nebivolol are appropriate options. 1, 2
Heart Failure with Reduced Ejection Fraction (HFrEF)
Only three beta blockers have demonstrated mortality reduction in heart failure—this is not a class effect. 1, 2
Bisoprolol
- Starting dose: 1.25 mg once daily 1, 2
- Target dose: 10 mg once daily 1, 2
- Titration: Double the dose every 1-2 weeks as tolerated 1
- Key advantage: Once-daily dosing with consistent beta-blockade 2
- Mortality benefit: 34% relative risk reduction in all-cause mortality 2
Carvedilol
- Starting dose: 3.125 mg twice daily 1, 2
- Target dose: 25-50 mg twice daily 1, 2
- Titration: Double the dose every 2 weeks if tolerated 1
- Key advantage: Combined alpha- and beta-blocking properties; may be superior to metoprolol in some studies 1, 2
- Extended-release formulation: Carvedilol CR 20-80 mg once daily is available 1, 2
Critical Distinction for Metoprolol Formulations
If continuing metoprolol, only metoprolol succinate extended-release (CR/XL) has proven mortality reduction—metoprolol tartrate (immediate-release) should not be used for heart failure. 2, 3, 4, 5
Hypertension
Beta blockers are not recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure. 1, 2
Cardioselective Beta-1 Blockers
- Atenolol: 25-100 mg once daily 1
- Bisoprolol: 2.5-10 mg once daily 1
- Metoprolol tartrate: 100-200 mg daily in divided doses 1
- Betaxolol: 10-20 mg once daily 1
- Nebivolol: 5-40 mg once daily (has nitric oxide-induced vasodilation) 1, 2
Non-Cardioselective Beta Blockers
Combined Alpha- and Beta-Blockers
Post-Myocardial Infarction
Agents studied in the acute setting include metoprolol, propranolol, atenolol, and carvedilol. 1 Beta blockers without intrinsic sympathomimetic activity are strongly preferred. 1
Special Populations and Considerations
Patients with Bronchospastic Disease
Cardioselective agents (bisoprolol, metoprolol, atenolol) are strongly preferred if a beta blocker is required, starting at reduced doses. 1, 2 Avoid non-selective agents like propranolol and nadolol. 1
Patients Requiring Once-Daily Dosing
- Bisoprolol, atenolol, nadolol, nebivolol, and metoprolol succinate CR/XL offer once-daily convenience 1
- Carvedilol CR (extended-release) provides once-daily dosing versus twice-daily for immediate-release 1, 2
Patients with Severe Renal Dysfunction
Atenolol can be removed by hemodialysis, which may be relevant in overdose situations. 6
Common Pitfalls to Avoid
Never use metoprolol tartrate (immediate-release) for heart failure—only metoprolol succinate extended-release has mortality data. 2, 3, 4, 5
Avoid beta blockers with intrinsic sympathomimetic activity (acebutolol, pindolol, penbutolol) in patients with ischemic heart disease or heart failure. 1
Never abruptly discontinue any beta blocker—this risks rebound hypertension, myocardial ischemia, infarction, and arrhythmias. 1, 2 Taper gradually over approximately one week. 2
Do not combine non-dihydropyridine calcium channel blockers (diltiazem, verapamil) with beta blockers due to increased risk of bradycardia and heart block. 1
Start low and titrate slowly in heart failure patients—initial worsening of symptoms may occur during titration, requiring adjustment of diuretics rather than stopping the beta blocker. 1, 2
Aim for target doses proven in clinical trials—if full target cannot be achieved, at least 50% of target dose provides mortality benefit. 2 Some beta blocker is better than no beta blocker. 2