beta blockers in cardiac failure

Last edited 10/2018

  • there is evidence that beta-blockers can improve prognosis in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (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 (3)

  • offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including (3):
    • 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 (3)

    • 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 bd or bisoprolol 10mg od (2,4)

  • 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 (4)
  • 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


  • 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 (5) - these results were regardless of pretreatment 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 (6)
  • 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 (7)
  • a meta-analysis has shown that beta-blockers appear to effectively reduce the occurrence of AF in patients with systolic HF (8)
  • heart rate reduction and beta blockers in heart failure
    • a meta-analysis (9) 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