Beta blockers in heart failure

Current guidance suggests that beta-blockers should be used in all patients with symptomatic heart failure and an LVEF ≤40%, where tolerated and not contra-indicated. Trial evidence shows beta-blockers increase ejection fraction and exercise tolerance and reduce morbidity, mortality and hospital admissions additional to that produced by co-prescription of ACE inhibitors.

They should be initiated in stabilised patients already on diuretics and ACE inhibitors, regardless of whether or not symptoms persist. (1,2)

• offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first
  
  
• offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
  • older adults and
  • patients with:
    • peripheral vascular disease
    • erectile dysfunction
    • diabetes mellitus
    • interstitial pulmonary disease and
    • chronic obstructive pulmonary disease (COPD) without reversibility
      
      
• introduce beta-blockers in a 'start low, go slow' manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker
• asthma, second- or third-degree heart block, sick sinus syndrome (without pacemaker) and sinus bradycardia (<50 beats per minute (bpm)) remain contra-indications to beta-blocker use.
  
  
  • beta-blocker therapy should be started at a very low dose (e.g. carvedilol 3.125mg once daily) and titrated slowly over a period of weeks or months
    • the beta-blocker should be up-titrated at fortnightly intervals (or longer in more sensitive patients) to a target dose of carvedilol 25-50mg b.d. or bisoprolol 10mg o.d.
      
      
• switch stable patients who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure due to left ventricular systolic dysfunction, to a beta-blocker licensed for heart failure
• there may be some early symptomatic deterioration during beta-blocker therapy
• beta-blockers do not provide an instant beneficial effect in CHF
  • initially patients may feel more tired and they may experience symptoms of worsening fluid retention requiring a temporary increase in diuretic therapy
  • beneficial effects on LV function can take 3 to 6 months to appear

Notes:

• there is evidence that carvedilol reduced the risk of all cause mortality and combined mortality and general and specific hospital admission in severe heart failure - these results were regardless of pre-treatment systolic blood pressure
• use of beta-blockers in in patients >/=70 years, regardless of ejection fraction. There is evidence that, in this patient population, nebivolol, a beta-blocker with vasodilating properties, is an effective and well-tolerated treatment for heart failure in the elderly
• the magnitude of the prognostic benefit conferred by beta-blockers in the absence of ACE-I appears to be similar to those of ACE-Is in systolic CHF
• a meta-analysis has shown that beta-blockers appear to effectively reduce the occurrence of AF in patients with systolic HF
• heart rate reduction and beta blockers in heart failure
  • one meta-analysis (3) found that the extent of heart rate reduction in patients with chronic heart failure treated with beta-blockers was significantly associated with survival benefit in trials, whereas the dose of beta-blocker was not
    • for every 5 beats/minute reduction in heart rate using beta-blocker treatment, the relative risk of death was decreased by 18%, although the heart rate reduction at which this benefit stops is not known

Reference

1. NICE. Acute heart failure: diagnosis and management. Clinical guideline CG187. Published October 2014, last updated November 2021
2. NICE. Chronic heart failure in adults: diagnosis and management. NICE guideline NG106. Published September 2018, last updated September 2025.
3. McAlister FA, Wiebe N, Ezekowitz JA, et al. Meta-analysis: beta-blocker dose, heart rate reduction and death in patients with heart failure. Ann Intern Med 2009;150:784-94