| Indication |
Recommendation |
| Stable angina |
Preferred: bisoprolol, metoprolol, atenolol
Beta blockers or calcium channel blockers are first line for patients with stable angina. N.B. Calcium channel blockers should generally be avoided in patients with angina and HFrEF.
All beta blockers are considered equally effective, although in practice, a cardioselective beta blocker (e.g. bisoprolol, metoprolol, atenolol) may be preferred as it is likely to provide the maximum effect with minimum adverse effects. |
| Arrhythmias |
Preferred: bisoprolol, metoprolol succinate, carvedilol
A beta blocker is usually initiated for long-term rate control in patients with a cardiac arrythmia. A rate-limiting calcium channel blocker (diltiazem, verapamil) is also a suitable first-line option for rate control for patients with atrial fibrillation.
Any beta blocker (apart from sotalol) can be used for rate control but bisoprolol (unapproved indication), metoprolol succinate or carvedilol (unapproved indication) are usually preferred. In practice, bisoprolol is often trialled first as it is more cardioselective than metoprolol and may slow the heart rate slightly more than other beta blockers. |
| Heart failure |
Preferred: bisoprolol, metoprolol succinate, carvedilol
International guidance is increasingly recommending that most patients with HFrEF should be established on the “four pillars of heart failure treatment” as early as possible: an ARNI, i.e. sacubitril + valsartan, beta blocker, MRA, e.g. spironolactone, eplerenone, and a SGLT-2 inhibitor, i.e. empagliflozin.
Bisoprolol, metoprolol succinate or carvedilol are the preferred beta blockers as they can reduce symptom severity, hospitalisation and mortality in people with HFrEF. Patient-specific factors guide choice. In patients with heart failure that is associated with atrial fibrillation, there is evidence that carvedilol is superior to metoprolol succinate; however, in practice, bisoprolol or metoprolol succinate is usually prescribed as these are cardioselective and generally dosed once daily. Bisoprolol may be preferred for patients experiencing hypotension or dizziness with an ARNI and carvedilol. Bisoprolol may maintain pulmonary function and protect from myocardial injury to a greater extent than carvedilol. |
| Post-myocardial infarction |
Preferred: bisoprolol, metoprolol, atenolol
A cardioselective beta blocker, e.g. bisoprolol, is usually prescribed to patients post-myocardial infarction, however, international guidelines do not recommend a specific beta blocker.
The optimal treatment duration of a beta blocker post-myocardial infarction in patients with preserved ejection fraction and no regional wall motion abnormalities (RWMA) on echocardiogram is uncertain. Evidence increasingly supports the withdrawal of beta blockers one year post-myocardial infarction in these patients (if they do not have other indications for treatment, e.g. heart failure, arrhythmias), as treatment beyond this period has not been associated with improved cardiovascular outcomes. A beta blocker is usually required indefinitely for patients with reduced left ventricular ejection fraction or evidence of myocardial damage as demonstrated by RWMA on echocardiogram.
|
| Hypertension |
Preferred: bisoprolol, metoprolol, atenolol, carvedilol
Beta blockers are no longer first line for the management of hypertension unless there is a specific clinical reason for their use, e.g. co-morbid atrial fibrillation or heart failure, female of reproductive age.
All beta blockers are considered equally effective for hypertension. In practice, a cardioselective or vasodilating beta blocker is usually prescribed. |
| Co-morbidities and considerations |
| Renal impairment |
Consider dose adjustment for water-soluble beta blockers or a lipid-soluble beta blocker may be better tolerated. Dose adjustments of bisoprolol are not usually required in renal impairment (unless impairment is severe). |
| Hepatic impairment |
Consider dose adjustment for lipid-soluble beta blockers (e.g. metoprolol, propranolol) or switch to a water-soluble beta blocker. Carvedilol should be avoided. Dose adjustments of bisoprolol are not usually required in hepatic impairment (unless impairment is severe). |
| Asthma |
Beta blockers are generally avoided in patients with asthma, however, if a beta blocker is required, prescribe a cardioselective beta blocker |
| COPD |
Cardioselective beta blockers are recommended |
| Diabetes |
Evidence suggests that carvedilol may be the preferred beta blocker for patients with cardiovascular disease and diabetes (or who are at increased risk) as it does not adversely affect glycaemic control and may improve insulin sensitivity. However, in practice, bisoprolol or metoprolol succinate is usually prescribed to these patients as these medicines are cardioselective and generally dosed once daily, whereas carvedilol is dosed twice daily and if there are issues with adherence, this would reduce the benefit. |
| Pregnancy |
Labetalol is usually first line if a beta blocker is indicated during pregnancy as it is generally associated with the lowest risk of adverse neonatal effects. Metoprolol or bisoprolol may be a suitable alternative if required. |
| Breast feeding |
Carvedilol, labetalol, metoprolol and propranolol are present in breast milk in low quantities but this is not expected to affect infants. Atenolol, sotalol and nadolol should generally be avoided while breast feeding (particularly for newborns and pre-term infants or if taking high doses) as they are excreted in breast milk in higher quantities. |
| Other considerations |
Cardioselective beta blockers (e.g. bisoprolol, metoprolol, atenolol) are less likely to cause cold extremities
Water-soluble beta blockers (e.g. atenolol) are less likely to cause central nervous system effects such as sleep disturbances
Bisoprolol is less likely to cause sexual dysfunction compared to other beta blockers |
