From the Guidelines
Beta blockers are a cornerstone therapy for heart failure patients, particularly those with reduced ejection fraction (HFrEF), and should be initiated with low doses and gradually increased to target doses, as recommended by the most recent guidelines 1. The recommended beta blockers for heart failure include carvedilol, metoprolol succinate, and bisoprolol.
- Treatment should begin with low doses and gradually increase to target doses:
- Carvedilol starting at 3.125 mg twice daily and titrating to 25-50 mg twice daily;
- Metoprolol succinate starting at 12.5-25 mg daily and titrating to 200 mg daily;
- Or bisoprolol starting at 1.25 mg daily and titrating to 10 mg daily. Dose increases should occur every 2 weeks as tolerated, monitoring for side effects such as hypotension, bradycardia, or worsening heart failure symptoms, as supported by the evidence from the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1. Beta blockers work by blocking sympathetic nervous system activation, reducing heart rate and blood pressure, which decreases cardiac workload and allows for beneficial cardiac remodeling, as described in the 2013 ACCF/AHA guideline for the management of heart failure 1. They should be initiated in stable patients, not during acute decompensation, and if a patient experiences worsening symptoms when starting therapy, the dose may need to be temporarily reduced rather than discontinued completely, as recommended by the European Society of Cardiology guidelines 1. Regular follow-up with blood pressure, heart rate, and symptom assessment is essential for successful beta blocker therapy in heart failure management, and the use of beta blockers has been shown to reduce mortality and hospitalization in patients with HFrEF, as demonstrated by the evidence from multiple studies 1.
From the FDA Drug Label
WARNINGS Heart Failure Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock. If signs or symptoms of heart failure develop, treat the patient according to recommended guidelines. It may be necessary to lower the dose of metoprolol or to discontinue it WARNINGS Cardiac Failure Sympathetic stimulation is a vital component supporting circulatory function in the setting of congestive heart failure, and beta-blockade may result in further depression of myocardial contractility and precipitate more severe failure.
The beta blocker regimen for heart failure patients involves using the medication with caution. Key considerations include:
- Using the lowest possible dose
- Monitoring the patient closely for signs of heart failure
- Being prepared to lower the dose or discontinue the medication if heart failure develops
- Tapering therapy over a period of 1 to 2 weeks if discontinuation is necessary, to avoid exacerbation of angina or other adverse effects 2, 3
- Considering the use of other medications to treat heart failure while continuing beta-blocker therapy.
From the Research
Beta Blocker Regimen for Heart Failure Patients
- The current recommendations of the American College of Cardiology/ American Heart Association suggest a mortality benefit with the use of β-blockers in chronic HF, especially for bisoprolol, carvedilol, and sustained-release metoprolol succinate 4.
- The use of these three agents should be recommended for all stable subjects with current or previous symptoms of heart failure and heart failure with reduced ejection fraction unless there is any contraindication 4.
- β-blockers in heart failure should be commenced at small doses and then titrated upward as tolerated to achieve the desired clinical effects on heart rate and symptom control 4.
Dosing of Beta Blockers
- The mean total daily dose for beta blockers before hospital admission was <1/2 the recommended target dose, with infrequent up- or down-titration during the HF hospitalization 5.
- At 60- to 90-day postdischarge follow-up, only 17.5% and 7.9% of patients were being treated with recommended target doses of carvedilol and metoprolol succinate, respectively 5.
- The doses of beta blockers applied in clinical practice are substantially less than the doses achieved in randomized clinical trials in HF and recommended in national guidelines 5.
Pharmacodynamics of Beta Blockers
- The Carvedilol Or Metoprolol European Trial (COMET) compared nonselective blockade of the beta1-/beta2-/alpha1-adrenergic receptors with carvedilol versus selective beta1-blockade with immediate-release metoprolol tartrate in patients with chronic heart failure 6.
- The trial found that carvedilol significantly reduced all-cause mortality compared with immediate-release metoprolol tartrate, although there were no differences in hospitalizations 6.
- The results of COMET demonstrate that all beta-blockers and dosage forms are not interchangeable when prescribed for heart failure 6.
Choice of Beta Blockers
- The choice of beta blocker is important as benefit is not a class-effect, and the possession of intrinsic sympathomimetic activity (ISA) diminishes efficacy 7.
- The choice is between bisoprolol, metoprolol succinate, and carvedilol for optimal efficacy 7.
- Adverse reactions are associated, mainly, with beta-2 blockade and alpha-blockade, and the possession of beta-2 blockade, particularly if combined with alpha-blockade, is associated with an increased occurrence of sexual dysfunction 7.
Use of Beta Blockers in Patients with Comorbidities
- β-blockers represent a mainstay in the pharmacological approach to patients affected by heart failure with reduced ejection fraction (HFrEF), and their prognostic benefit is relevant in the presence of comorbidities 8.
- Achievement of the maximum tolerated dose is an important goal to increase their favorable prognostic role, and the role and most appropriate beta-blocker in patients with pulmonary disease, diabetes, atrial fibrillation, erectile dysfunction, peripheral arterial disease, and other conditions should be considered 8.