The beta-blockers bisoprolol and carvedilol have been shown to reduce mortality (by about 30%) and hospital admissions (by about 20%) when added to full conventional heart failure (HF) therapy, including ACE inhibitor treatment.

Higher doses are more beneficial, hence the need to optimise doses. For those patients unable to tolerate BNF maximum doses, a small dose of beta blocker is better than none.

This advice applies to monitoring of pharmacotherapy in clinically stable patients; it does NOT apply to patients with intercurrent acute illness.

Bisoprolol – adjunct in stable moderate to severe heart failure with reduced systolic ventricular function (EF<35% on echo). It is recommended that the treating physician should be experienced in the management of chronic heart failure. Bisoprolol is cardio selective and therefore should be the preferred agent if beta-blockers are used in patients with respiratory problems.

Carvedilol – used as an adjunct to diuretics, digoxin or ACE inhibitors in symptomatic chronic heart failure. Initiation should be under the supervision of a hospital physician.

Nebivolol – 5mg only on FPH formulary. Can be halved.

Bisoprolol and carvedilol are lipid soluble and therefore can cross the blood brain barrier however bisoprolol is less likely to cause CNS disturbances.

“Patients who have HFrEF who do not have REVERSIBLE chronic obstructive pulmonary disease should be considered for the introduction of betablockers at low doses. These should be uptitrated slowly” CG106 NICE Guidance.

For HFmrEF, beta-blockers may be considered as additional therapy to reduce mortality and hospitalisation.

Bisoprolol is the preferred agent, with carvedilol a suitable second-line alternative.

Treatment should be initiated and titrated by those experienced in the management of heart failure.

Ensure the patient is symptomatically stable and other heart failure therapies have been mainly unchanged for 2 weeks.

Observe contra-indications and cautions and start with a low dose (see table below) 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.

It is suggested to double the dose at not less than 4 weekly intervals as long as the patient is clinically stable, but this may be done more cautiously (see table below)

Aim for a target dose as detailed below, failing that, aim for the maximum tolerated dose. Some beta-blocker is better than no beta-blocker.

Monitor heart rate, blood pressure, clinical status, symptoms and signs of congestion, e.g., body weight, breathlessness and oedema. An ECG is recommended before initiation in patients with a heart rate less than 60 beats per minute.

Check blood electrolytes, urea and creatinine 1-2 weeks after initiation and 1-2 weeks after final dose titration.

NICE recommend that patients already on an unlicensed beta-blocker for heart failure should be switched to a licensed beta-blocker

If a beta-blocker has been stopped for more than 2 weeks, re-introduce cautiously. Consider restarting from the initiation dose.

Suggested dose titration schedule

*maximum dose in patients with severe heart failure or body weight <85kg

**maximum dose for those with body weight >85kg

Worsening symptoms/signs

(e.g., increasing dyspnoea, fatigue, oedema, weight gain >1.5kg over 3days)

• If increased congestion, increase dose of diuretic and/or halve dose of beta-blocker (if increasing diuretic does not work)

• If marked fatigue (and/or bradycardia, see below) halve dose of beta blocker (rarely necessary)

• Review patient in one to two weeks. If there has been no improvement, seek specialist advice.

• If serious deterioration, halve the dose of beta-blocker or stop treatment (rarely necessary) and seek specialist advice.

• If there are worsening symptoms of airways disease, stop the beta-blocker and seek specialist advice as appropriate.

Asymptomatic low blood pressure

• Does not usually warrant a change in therapy

Symptomatic low blood pressure

• If combined with dizziness, light-headedness or confusion, consider discontinuing drugs such as nitrates, calcium channel blockers and other vasodilators

• If no signs/symptoms of congestion, consider reducing dose of diuretic.

• If these measures do not solve problem, seek specialist advice.

Bradycardia (HR<50)

• If bradycardia and worsening symptoms, halve the dose of beta-blocker or if severe deterioration, stop beta-blocker (rarely necessary)

• Consider need to continue treatment with other drugs used to slow the heart (digoxin, amiodarone, diltiazem) and discontinue if co-morbidities allow. Consider referral if in doubt

• Arrange ECG to exclude heart block

• Seek specialist advice

2^nd or 3^rd degree heart block

• Stop beta-blocker and consult specialist advice (patient may require hospital admission)

• Undertake a further ECG after beta-blocker stopped

Admission with Acute Heart Failure (HFrEF)

• If in acute heart failure but already taking beta-blockers – continue taking beta-blockers unless HR<50, shock or second- or third-degree heart block

• Start or restart beta-blocker treatment during hospital admission, once condition has stabilised, for example when intravenous diuretics no longer needed.

• Before discharging from hospital - ensure patient’s condition is stable for typically 48 hours, after starting or restarting beta-blockers

Impotence

Discuss with patient and Doctor. This may resolve as heart failure improves although a referral to the erectile dysfunction clinic should be offered.

• Explain the expected benefits and emphasise that the treatment given is to prevent worsening of heart failure, improve symptoms and increase survival

• Symptomatic improvement may take up to 3-6 months or longer to develop

• Temporary symptomatic deterioration may occur during initiation and/or up titration in approximately 20-30% of cases. Advise patients to report deterioration (fatigue, breathlessness and tiredness) and that deterioration can usually be easily managed by adjustment of other medication.

• Patients should be advised not to stop their beta-blocker therapy without speaking to their healthcare professional.

• Patients should be encouraged to weigh themselves daily (after waking and voiding but before breakfast and dressing) and to consult their GP/heart failure team if they have persistent weight gain (e.g., an increase in your weight of more than 1.5-2kg in 3 days).

• Carvedilol should be taken with food

Chronic Heart Failure in Adults: Diagnosis and Management. NICE clinical Guideline CG106. Issued September 2018. Available at: www.nice.org.uk/guidance/ng106.

National Institute for Health and Care Excellence (2014. Updated 2021). Acute heart failure: diagnosis and management. Clinical guideline. Available at: https://www.nice.org.uk/guidance/cg187 (Accessed 07.03.22)

Summary of product characteristics for Cardicor. Available online at www.medicines.org.uk/

Summary of product characteristics for Eucardic. Available online at www.medicines.org.uk/

Summary of product characteristics for Nubile. Available online at www.medicines.org.uk/ British National Formulary

Theresa A McDonagh et al, 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 42, Issue 36, 21 September 2021, Pages 3599–3726, https://doi.org/10.1093/eurheartj/ehab368

With thanks to the Sussex Heart Network, from whom these guidelines were adapted

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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