From the Guidelines
The preferred beta blockers for heart failure are carvedilol, metoprolol succinate, and bisoprolol, which have been proven to reduce mortality and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF) 1. These specific beta blockers are beneficial in heart failure because they block harmful neurohormonal activation, reduce heart rate and cardiac workload, prevent arrhythmias, and promote beneficial cardiac remodeling over time.
- The typical starting dose for carvedilol is 3.125 mg twice daily, gradually titrated up 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 200 mg daily.
- Bisoprolol is initiated at 1.25 mg daily and increased to 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 1. Not all beta blockers have these benefits in heart failure, which is why these three are specifically recommended. The use of these beta blockers is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality 1.
From the FDA Drug Label
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. WARNINGS Heart Failure Beta-blockers, like metoprolol, can cause depression of myocardial contractility and may precipitate heart failure and cardiogenic shock.
The FDA drug label does not answer the question.
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 heart failure 2, 3, 4, 5, 6.
Key Characteristics of Preferred Beta Blockers
- Bisoprolol, carvedilol, and metoprolol succinate have been clearly proven to reduce mortality and hospitalization in patients with Class II to IV heart failure 3.
- These beta blockers should be initiated at low doses and titrated upward as tolerated to achieve the desired clinical effects on heart rate and symptom control 2, 3.
- The choice of beta blocker is important, as benefit is not a class-effect, and the presence of intrinsic sympathomimetic activity (ISA) diminishes efficacy in the treatment of systolic heart failure 5.
Comparison of Preferred Beta Blockers
- Bisoprolol and carvedilol have been associated with lower mortality compared to metoprolol succinate in some studies 4.
- Carvedilol has been shown to have a significant reduction in mortality compared to metoprolol tartrate in the COMET trial 6.
- The differences in effects between beta blockers may be related to their ancillary properties, such as antioxidant, anti-endothelin, and antiproliferative properties, or to their broader antiadrenergic profile 6.
Initiation and Titration of 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 2, 3.
- The initiating dose should be very low (1.25 mg bisoprolol, 3.125 mg carvedilol, 12.5 mg metoprolol succinate) and increased gradually over weeks 3.
- Treatment benefit appears proportional to magnitude of heart rate reduction, and thus target dose should be the maximum tolerated for adequate bradycardia 3.