Beta blockers have mortality benefit in patients with HFrEF. Only Bisoprolol, Metoprolol succinate, Carvedilol, & Nebivolol have proven benefits in HFrEF. Carvedilol is a non selective beta blocker and Bisoprolol, Metoprolol, and Nebivolol are cardioselective beta blockers. All patients with HFrEF should be started on the beta blockers as soon as possible. However we need to be cautious while initiating the beta blockers. The choice of the beta blockers depends upon various factors but comorbidities is one of them which dictates the choice of beta blockers.
In patients with pulmonary diseases the beta blockers including bisoprolol, nebivolol, and metoprolol are preferred. Bisoprolol is the first choice among them for patients with pulmonary diseases.
Patients with diabetes is the next group in which beta blockers should be used with some caution. Beta blockers can mask the symptoms of hypoglycemia. Carvedilol and Nebivolol are the preferred agensts in diabetic patients.
In patients with atrial fibrillation all of the four, Bisoprolol, Metoprolol, Carvedilol, Nebivolol, are indicated for the rate control. Metoprolol is usally the first choice in patients with atrial fibrillation and heart failure.
In patients with erectile dysfunction the Bisoprolol and Nebivolol are the preferred beta blokcers in patients with heart failure. Similary the patients with HFrEF who also have peripheral artery disease (PAD) are better treated with beta blocker with vasodilatory property, Nebivolol , is preferred.
In the patients with cirrhosis of liver Carvedilol is increasingly used due to its greater portal pressure reducing effect than propanolol, and safety in compensated and decompensated cirrhosis.
The absolute contraindication to beta blocker use are true severe asthma and second and third degree heart blocks. Non severe asthma is a relative contraindication and COPD is not a contraindication. However beta blockers should be used cautiously in patients with severe or advanced heart failure, current or recent worsening of heart failure, heart rate less than sixty, and persisting signs of congestion.
MBBS, MD (Internal Medicine)
