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 use of these beta blockers is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality.
- The typical starting dose for carvedilol is 3.125 mg twice daily, gradually titrated up to a target of 25 mg twice daily 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 work by blocking harmful effects of the sympathetic nervous system on the failing heart, reducing heart rate, improving cardiac remodeling, and decreasing oxygen demand. They should be started at low doses and gradually increased to target doses over several weeks while monitoring for side effects such as hypotension, bradycardia, and worsening heart failure symptoms. Beta blockers should be initiated when patients are euvolemic and relatively stable, not during acute decompensation, as stated in the 2013 ACCF/AHA guideline for the management of heart failure 1. The evidence base for beta blockers in heart failure has been established only for some beta blockers (bisoprolol, metoprolol succinate, carvedilol, and nebivolol), and therapy in patients who develop heart failure while already receiving treatment for a comorbid condition should be switched to one of these beta blockers 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 heart failure 2, 3, 4.
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 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 2.
Comparison of Beta Blockers
- Bisoprolol and carvedilol were both associated with lower mortality as compared with metoprolol succinate in univariable analysis 4.
- However, there was no significant association between beta-blocker choice and all-cause mortality in any of the matched samples 4.
- Carvedilol was nonselective at all clinically relevant doses, whereas metoprolol succinate was beta(1)-selective at low doses and became progressively nonselective at higher doses 5.
Clinical Considerations
- The choice of beta blocker is important, as benefit is not a class-effect 6.
- Adverse reactions are associated with beta-2 blockade and alpha-blockade, and the possession of alpha-blocking activity is associated with dizziness and postural hypotension 6.
- Lipophilic beta blockers like propranolol and metoprolol appear in high concentrations in human brain tissue and are associated with side-effects such as insomnia, dreams, and nightmares 6.