Beta Blocker Initiation in Heart Failure

Beta blockers reduce death and admission in heart failure with reduced ejection fraction. Only bisoprolol, carvedilol, metoprolol succinate and nebivolol have this effect. They are started in a stable, euvolaemic person, at low dose, and increased slowly. Worsening symptoms in the first weeks usually reflect fluid retention and are treated with a diuretic rather than stopping the beta blocker.

Start criteria. No fluid overload, systolic pressure of 100 mmHg or over, heart rate of 60 beats a minute or over, no second or third degree heart block and no severe asthma.

Timing. Start before discharge once congestion has settled, or at the first outpatient visit.

Bisoprolol. 1.25 mg orally once daily, doubled every 2 to 4 weeks to the target of 10 mg daily.

Carvedilol. 3.125 mg orally twice daily with food, doubled every 2 to 4 weeks to 25 mg twice daily (50 mg twice daily if weight is over 85 kg).

Metoprolol succinate. 12.5 to 25 mg orally once daily, doubled every 2 to 4 weeks to 200 mg daily.

Nebivolol. 1.25 mg orally once daily, doubled every 2 to 4 weeks to 10 mg daily. Studied in people aged 70 or over.

Special groups. In older adults start at the lowest dose and step slowly. In pregnancy atenolol is avoided, and metoprolol or labetalol are preferred. In chronic obstructive pulmonary disease, bisoprolol and nebivolol are usually tolerated. In asthma, avoid. In hepatic impairment avoid carvedilol in severe disease and reduce the dose of metoprolol. In creatinine clearance under 20 mL/min use bisoprolol up to 10 mg daily. In diabetes, hypoglycaemia symptoms may be masked, except sweating.

Interactions. Verapamil and diltiazem (heart block, avoid), digoxin and amiodarone (bradycardia), insulin and clonidine (rebound hypertension if clonidine stops first).

Monitoring. Heart rate, pressure, weight and symptoms at 1 to 2 weeks after each step. ECG for heart rate under 50 beats a minute.

Worsening congestion. Increase the diuretic first and continue the beta blocker. If the person is hypotensive or congested and unwell, halve the dose.

Bradycardia or hypotension. Reduce the dose by half and review other rate-lowering and vasodilating drugs.

Stopping. Do not stop suddenly because of rebound tachycardia and ischaemia. Stop only for cardiogenic shock, symptomatic high-grade heart block, or severe bronchospasm.

Common errors. Starting in decompensated heart failure, doubling too quickly, using atenolol, and stopping for fatigue in the first weeks.

Referral and escalation. Refer for heart rate under 40 beats a minute, high-grade block, recurrent hospital admission, or ejection fraction of 35% or under despite 3 months of treatment.