Beta-Blocker Replacement in Heart Failure with Reduced Ejection Fraction

Evidence-Based Alternatives

The American College of Cardiology and American Heart Association recommend replacing bisoprolol with either carvedilol or sustained-release metoprolol succinate in patients with heart failure with reduced ejection fraction (HFrEF), as these are the only other beta-blockers with proven mortality reduction in this population 1, 2
The American College of Cardiology recommends bisoprolol (target dose 10 mg once daily) as one of the three beta-blockers that have demonstrated mortality reduction in large-scale trials for HFrEF 3
The American College of Cardiology recommends metoprolol succinate (sustained-release) (target dose 200 mg once daily) as one of the three beta-blockers that have demonstrated mortality reduction in large-scale trials for HFrEF 4

For patients with HFrEF, the American College of Cardiology recommends starting carvedilol at 3.125 mg twice daily and titrating every 2 weeks to a target dose of 25 mg twice daily (or 50 mg twice daily if ≥85 kg), with a 65% mortality reduction shown in the US Carvedilol Heart Failure Program and 35% reduction in the COPERNICUS trial for advanced heart failure 3, 7
For patients with HFrEF, the American College of Cardiology recommends starting metoprolol succinate (sustained-release) at 12.5-25 mg once daily and titrating every 2 weeks to a target dose of 200 mg once daily, with a 34% reduction in all-cause mortality demonstrated in the MERIT-HF trial 3, 5
For patients with post-myocardial infarction and left ventricular systolic dysfunction (EF ≤40%), the American College of Cardiology recommends using carvedilol or metoprolol succinate, and continuing beta-blocker therapy for at least 3 years in all patients with normal left ventricular function after myocardial infarction or acute coronary syndrome 2

When switching from bisoprolol to another beta-blocker, the American Heart Association recommends starting the replacement beta-blocker at a low initial dose while tapering bisoprolol, with carvedilol started at 3.125 mg twice daily and metoprolol succinate started at 12.5-25 mg once daily 3, 7, 5
The American Heart Association recommends titrating the replacement beta-blocker gradually every 2 weeks to the target dose if tolerated, with monitoring for bradycardia, hypotension, worsening heart failure symptoms, and fluid retention 6, 9, 10

The American College of Cardiology provides approximate equivalent doses to bisoprolol 5 mg, including metoprolol succinate 50-100 mg once daily and carvedilol 12.5 mg twice daily 8
The American College of Cardiology recommends target doses for HFrEF, including bisoprolol 10 mg once daily, carvedilol 25 mg twice daily (<85 kg) or 50 mg twice daily (≥85 kg), and metoprolol succinate 200 mg once daily 4, 9, 10

For patients with renal impairment, the American College of Cardiology recommends dose adjustments, including a maximum of 50 mg daily for atenolol with creatinine clearance 15-35 mL/min and a maximum of 25 mg daily for creatinine clearance <15 mL/min 9
For elderly patients, the American College of Cardiology recommends starting at the lower end of the dosing range, assessing renal function before initiating therapy, and titrating more cautiously 6, 9

The American College of Cardiology recommends avoiding the use of immediate-release metoprolol tartrate, atenolol, bucindolol, and nebivolol in patients with HFrEF due to lack of mortality data or diminished efficacy 4, 3, 7, 9