What beta blocker is recommended for treating hypertension or heart failure?

Beta-Blocker Selection for Heart Failure and Hypertension

For heart failure with reduced ejection fraction (HFrEF), use one of three evidence-based beta-blockers proven to reduce mortality: bisoprolol, carvedilol, or metoprolol succinate extended-release—these are NOT interchangeable with other beta-blockers, as mortality benefit is not a class effect. 1

Heart Failure with Reduced Ejection Fraction (HFrEF)

First-Line Beta-Blocker Options

Only three beta-blockers have demonstrated mortality reduction in large clinical trials and should be used 1:

• 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 (depending on weight <85 kg or ≥85 kg) 1, 2
• Metoprolol succinate extended-release (CR/XL): 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. Short-acting metoprolol tartrate was less effective in HF clinical trials 1.

Comparative Efficacy

All three agents reduce all-cause mortality by approximately 34% and hospitalizations by 40% in NYHA class II-III heart failure 1, 2. While guidelines treat these as equivalent options 1, some evidence suggests potential differences:

• Carvedilol may offer theoretical advantages due to combined alpha-1, beta-1, and beta-2 blockade, plus antioxidant properties 3, 4
• Bisoprolol demonstrated "non-inferiority" to enalapril as first-line therapy and may be superior in reducing sudden death 5
• Metoprolol succinate achieved 34% mortality reduction, 38% cardiovascular mortality reduction, and 41% sudden death reduction in MERIT-HF 2, 6

Titration Protocol

Initiate beta-blockers as soon as HFrEF is diagnosed, even if symptoms are mild—do not wait for symptom progression 1. Start with low doses and double every 2 weeks as tolerated 1, 2:

• Monitor heart rate, blood pressure, clinical status, and signs of congestion at each visit 2
• Check blood chemistry at 1-2 weeks after initiation and dose changes, then 12 weeks after final titration 1, 2
• Aim for target doses used in clinical trials, but if not tolerated, maintain at least 50% of target dose 2
• Some beta-blocker is better than no beta-blocker when target doses cannot be achieved 2

Managing Adverse Effects During Titration

For worsening congestion 2:

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

For marked fatigue or bradycardia 2:

• Halve beta-blocker dose if heart rate <50 bpm with worsening symptoms

For symptomatic hypotension 2:

1. First: Reduce or eliminate vasodilators (nitrates, calcium channel blockers)
2. Second: Reduce diuretic dose if no congestion present
3. Third: Temporarily reduce beta-blocker dose by 50%
4. Last resort: Seek specialist advice before discontinuation

Critical Contraindications and Warnings

Absolute contraindications 1, 7:

• Current or recent (within 4 weeks) heart failure exacerbation requiring hospitalization
• Second or third-degree heart block without pacemaker
• Severe bradycardia (<50 bpm)
• Active asthma or severe reactive airways disease

Never abruptly discontinue beta-blockers—risk of rebound myocardial ischemia, infarction, and ventricular arrhythmias 1, 2, 7. If discontinuation necessary, taper over 1-2 weeks under close surveillance 7, 8.

Hypertension

Beta-blockers are NOT recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure 1, 2. When indicated, options include 1:

• Atenolol: 25-100 mg once daily (but less preferred due to lack of mortality data)
• Metoprolol tartrate: 100-200 mg daily in divided doses
• Bisoprolol: 2.5-10 mg once daily
• Carvedilol: 12.5-50 mg daily in divided doses
• Nebivolol: 5-40 mg once daily (offers nitric oxide-induced vasodilation)

For hypertensive patients with concurrent HFrEF, follow the heart failure dosing regimen with bisoprolol, carvedilol, or metoprolol succinate 2.

Special Populations and Considerations

Patients with bronchospastic disease: If beta-blocker required, use cardioselective agents (bisoprolol or metoprolol) at lowest effective dose 1, 7. Have bronchodilators readily available 7.

Patients with diabetes: Beta-blockers may mask hypoglycemia symptoms (especially tachycardia), but benefits in HFrEF outweigh risks 1, 7, 8.

Perioperative management: Do not routinely withdraw chronically administered beta-blockers before major surgery 7, 8. If withdrawal necessary, taper gradually and monitor closely 7.

Drug interactions: Avoid combining beta-blockers with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to significant negative inotropic and chronotropic effects 1, 8.

Common Pitfalls to Avoid

• Using metoprolol tartrate instead of metoprolol succinate for HFrEF—only the extended-release formulation has mortality data 1, 2
• Underdosing due to fear of side effects—aim for at least 50% of target dose for mortality benefit 2
• Stopping beta-blockers during acute decompensation—instead, optimize diuretics first and only reduce beta-blocker if necessary 2
• Abrupt discontinuation—always taper over 1-2 weeks to prevent rebound ischemia 2, 7, 8
• Initiating beta-blockers before ACE inhibitor/ARB therapy is established—background renin-angiotensin system inhibition should be present 2