What’s the best beta blocker for heart failure?

Beta blockers are well-tested and versatile medications. Healthcare providers have been prescribing them since the 1970s. Beta blockers have FDA approval to treat everything from glaucoma to migraines. But, they are also used for the treatment of cardiovascular conditions—often as a first-line treatment for heart failure.  

How do beta blockers work?

Beta blockers work by limiting the effects of epinephrine (also known as adrenaline)—a stress hormone. This slows your heartbeat, decreases blood pressure, and opens blood vessels to improve blood flow. These medications can treat high blood pressure (hypertension), irregular heart rhythms (arrhythmia), chest pains, heart failure, migraines, and heart attacks.

For patients with heart failure, “beta blockers typically work [to reduce stress on the heart] by reducing a patient’s heart rate,” explains Dawn Shill, Pharm.D., a pharmacist for the Veteran’s Affairs Healthcare System in Anchorage, Alaska.

Beta blockers help to improve the balance of myocardial supply and demand. Dr. Shill says, “Basically, sometimes heart failure is ischemic.” Meaning, there is weakened muscular tissue in the heart that leads to a decreased amount of blood pumped from the heart. Beta blockers can help improve function in certain areas of the heart by reducing the amount of oxygen supply needed for the heart to function at an optimal level.

Research also shows that beta blockers reduce the release of norepinephrine. Along with epinephrine, norepinephrine normally binds to receptors throughout the body and is involved with blood pressure and heart rate. Blocking the binding of these neurotransmitters to their receptors helps reduce heart rate and blood pressure. 

Which beta blockers can be used for heart failure?

Beta blockers are often given to patients experiencing a heart attack with the goal being to prevent a second heart attack from happening.

The American College of Cardiology specifically recommends the following beta blockers, which are FDA approved for heart failure:

• Coreg (carvedilol)
• Toprol XL (metoprolol succinate)
• Zebeta (bisoprolol)

It is important to note that only the extended-release version of metoprolol (metoprolol succinate) is approved by the FDA for heart failure, not metoprolol tartrate.

When using these beta blockers for heart failure treatment, they prevent the heart from being overstimulated and pumping too often, explains Jason Reed, Pharm.D.

“Most beta blockers also decrease how hard the heart muscle pumps,” Dr. Reed explains. “But these beta blockers do not do that, which is why they are able to treat the disease without making symptoms worse.”

In terms of differences between the beta blockers used for heart failure, he says, carvedilol blocks beta-1 beta-2 receptors in the heart, as well as alpha-1 receptors in the blood vessels. Metoprolol and bisoprolol primarily block beta-1 receptors in the heart. Although these beta blockers have some differences, they are effective at protecting the heart and reducing the risk of problems from heart failure. 

The best beta blockers for heart failure
Brand name (Generic name)	Dosage	Efficacy (compared to placebo)	Side effects	Learn more	Get coupon
Coreg (carvedilol)	3.125 mg twice daily for 2 weeks, followed by a dose increase every 2 weeks until desired results are achieved. Maximum of 25 mg twice daily for patients weighing less than 85 kg and 50 mg twice daily for patients weighing more than 85 kg.	65% reduction of mortality risk	Dizziness, fatigue, headaches, weight gain, diarrhea	Learn more	Get coupon
Toprol XL (metoprolol succinate)	12.5 to 25 mg once daily for 2 weeks, then increased every 2 weeks until desired results are achieved. Maximum of 200 mg per day.	34% reduction of mortality risk	Dizziness, depression, fatigue, wheezing, diarrhea	Learn more	Get coupon
Zebeta (bisoprolol)	1.25 mg once daily for 2 days, then 2.5 mg once daily for the first month, then 5 mg once daily. Maximum of 10 mg per day.	34% reduction of mortality risk	Headache, dizziness, joint pain, diarrhea, fatigue	Learn more	Get coupon

 

Which medication you are prescribed may depend on the severity of heart failure you are experiencing. Your doctor will also consider any previous treatments you have tried and any side effects you have experienced before. For example, bisoprolol works as well as other beta blockers for heart failure, but it may cause less fatigue than non-selective beta blockers like carvedilol.

 

When (and how) beta blockers are prescribed

Beta blockers do not strengthen the heart, they simply stop the nervous system from overstimulating it. “This prevents the heart muscle from overworking itself to hypertrophy due to excessive strain, which can lead to cardiomyopathy,” Dr. Reed explains.

While beta blockers can reduce damage to the heart by taking the strain off, Dr. Shill explains that if taken incorrectly they could actually weaken the heart. When not taken as prescribed, they can do more harm than good. Beta blockers can cause a dangerously low heart rate called bradycardia which can lead to low blood pressure. This can cause symptoms like dizziness, nausea, fainting, lack of concentration, or blurred vision.

So long as a patient is stable and the right beta blocker is prescribed in the right dose, beta blockers can be successfully used to treat heart failure. “The sympathetic nervous system is overacting and putting strain on the heart and that is why beta blockers will be initiated and then continued,” Dr. Reed says. “After a bout of acute heart failure, most patients will continue beta blocker therapy. Beta blockers have been shown to reduce mortality, and there is strong evidence supporting their use.”

Patients may be prescribed a low dose of beta blocker for heart failure to begin with. They can then monitor for any side effects under the supervision of a doctor for a week or two. As long as the medication is tolerated well, a healthcare provider can gradually increase the dose until symptoms are relieved, according to Dr. Reed.

Who should not use beta blockers?

While beta blockers can be life-saving for some patients, that isn’t the case for everyone. If a patient is experiencing congestive heart failure along with other comorbid conditions like COPD, diabetes or peripheral vascular disease, beta blockers may not be the right course of treatment. “Beta blockers should be avoided by patients who have asthma and COPD,” Dr. Reed says. “They are also not a good idea for patients with a slow heart rate or low blood pressure.”

Like all medications, beta blockers can have side effects.

“Postural hypotension is a problematic side effect for many people with beta blockers,” Dr. Reed explains. This can cause dizziness or fainting.

Some beta blockers can also cause side effects such as depression, fatigue, and erectile dysfunction, which can be a few of the most problematic side effects of these medications.

Then there are potential drug interactions to consider. “Some of the most commonly used drugs that interact with beta blockers include NSAIDs and anti-ulcer medications,” Dr. Reed says.

In addition to NSAIDs and anti-ulcer medications, there is a long list of possible interactions to be aware of. Patients should talk to their doctors about the safety of beta blocker treatment if they are taking any of the following:

• Blood pressure lowering drugs
• Other heart medications like antianginal or antiarrhythmic drugs
• Psychotropic drugs like antidepressants
• Anesthetics
• Statin medications
• Warfarin
• Diabetes medications
• Certain antibiotics like Rifampin 

In most cases, beta blockers are an effective treatment for heart failure, decreasing the risk of death from heart failure, and reducing the risk of recurrent heart attacks. Talk to your doctor about any concerns you may have, and be sure to report any side effects you experience while using a beta blocker.