What is the preferred beta blocker (beta-adrenergic blocking agent) for heart failure?

From the Guidelines

Carvedilol, metoprolol succinate, and bisoprolol are the preferred beta blockers for heart failure, with carvedilol often considered first-line, as they have been proven to reduce mortality and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF) 1. The typical starting dose for carvedilol is 3.125 mg twice daily, gradually titrated upward to a target of 25 mg twice daily (or 50 mg twice daily for patients over 85 kg) as tolerated. For metoprolol succinate, start with 12.5-25 mg once daily and titrate to a target of 200 mg daily. Bisoprolol is initiated at 1.25 mg daily and increased to a target of 10 mg daily. These medications should be started at low doses and gradually increased over weeks to months to reach target doses, with careful monitoring for side effects such as hypotension, bradycardia, and worsening heart failure symptoms. Some key points to consider when using these beta blockers include:

• They work by blocking harmful neurohormonal activation in heart failure, reducing cardiac workload, and allowing for beneficial cardiac remodeling over time 1.
• They should be part of a comprehensive heart failure regimen that typically includes ACE inhibitors or ARBs, mineralocorticoid receptor antagonists, and possibly newer agents like SGLT2 inhibitors.
• The benefits of beta-blockers cannot be assumed to be a class effect in heart failure, and only certain beta-blockers, such as bisoprolol, carvedilol, and metoprolol, have shown to reduce mortality in heart failure 1. The use of these specific beta blockers is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality 1.

From the Research

Preferred Beta Blockers for Heart Failure

The preferred beta blockers for heart failure are bisoprolol, carvedilol, and metoprolol succinate, as they have been shown to reduce mortality and hospitalization in patients with Class II to IV heart failure 2, 3.

Key Characteristics of Preferred Beta Blockers

• Bisoprolol, carvedilol, and metoprolol succinate have been clearly proven to reduce mortality and hospitalization in patients with heart failure 2.
• These beta blockers should be initiated at low doses and increased gradually over weeks 2, 3.
• The treatment benefit appears proportional to the magnitude of heart rate reduction, and the target dose should be the maximum tolerated for adequate bradycardia 2.
• Even in decompensated heart failure or those with coexisting bronchospasm, beta blockers are not contraindicated, although the dose may have to be reduced or withheld temporarily 2.

Comparison of Beta Blockers

• A study comparing bisoprolol, carvedilol, and nebivolol found that peak beta-blocking effects of bisoprolol appear stronger than those of nebivolol and carvedilol, but beta-blocking effects of all three drugs are similar at trough 4.
• Another study found that bisoprolol and carvedilol were associated with lower mortality compared to metoprolol succinate, but there was no significant association between beta-blocker choice and all-cause mortality in matched samples 5.
• A perspective on the role of four beta-blockers in heart failure found that bisoprolol, carvedilol, and metoprolol succinate have consistent trial data showing a mortality benefit, and should be recommended for all stable subjects with heart failure unless there is a contraindication 3.

Initiating Beta Blockers

• Beta blockers should be commenced at small doses and then titrated upward as tolerated to achieve the desired clinical effects on heart rate and symptom control 3.
• The initial dose should be very low, such as 1.25 mg bisoprolol, 3.125 mg carvedilol, or 12.5 mg metoprolol succinate, and increased gradually over weeks 2.