Initiatiating and titrating Beta-blockers in Heart Failure Print E-mail

When to initiate treatment

  • stable patients with heart failure due to left ventricular systolic dysfunction (LVSD), ie patients on the practice LVD register
  • all grades of heart failure (NYHA class I to IV).
  • seek specialist advice before starting beta-blockers in someone with a current or recent exacerbation of heart


  • people with a history of asthma or bronchospasm (beta-blockers can be used in people with COPD but caution should be used if severe)
  • second or third-degree heart block (in the absence of a permanent pacemaker)
  • sick sinus syndrome
  • sinus bradycardia (less than 50 beats per minute at the start of treatment)
  • severe hypotension.

Which beta-blocker and what dose?

  • only start a beta-blocker once the person is stable (without fluid overload or hypotension)
  • first choice - bisoprolol once daily, carvedilol twice daily may also be used but is more expensive
  • people already on beta-blockers for an existing condition eg angina or hypertension should continue either with their existing beta-blocker or an alternative licensed for heart failure treatment
  • start at a low dose and titrate up slowly to the target dose or the highest tolerated dose
  • do not increase dose if signs of worsening heart failure, symptomatic hypotension such as dizziness or excessive bradycardia (less than 50 beats per minute)
  • continue treatment at the target dose (or highest tolerated dose) indefinitely unless complications occur.



 WEEK 1   




 WEEK 11

 WEEK 15

(once daily) 







(twice daily)







Side effects

  • deteriorating symptoms of heart failure such as congestive symptoms and fatigue
  • hypotension
  • abnormally low heart rate (bradycardia)
  • cold extremities, paraesthesiae, and numbness more commonly in people with peripheral vascular disease
  • impotence and loss of libido.

Monitoring and problem solving

  • Beta-blockers should not be stopped suddenly unless absolutely necessary. Ideally seek specialist advice before stopping a beta-blocker
  • Monitor clinical status for symptoms and signs of heart failure, particularly after each dose increase.
    If worsening, eg increasing dyspnoea, fatigue, oedema, or weight gain, consider the following actions:
    • increasing oedema - double the dose of diuretic and if this does not work, consider halving the dose of beta-blocker
    • marked fatigue - halve the dose of beta-blocker
    • serious deterioration for example pulmonary oedema - halve the dose or stop the beta-blocker (seek specialist advice)
    • review the person in one to two weeks. If there is no improvement, seek specialist advice.
  • Check heart rate after each dose increase; if heart rate drops to 50 beats per minute or less, consider the following:
    • halve the dose of beta-blocker, or if symptoms deteriorate, stop the beta-blocker (seek specialist advice)
    • review and consider stopping other drugs that slow heart rate such as digoxin, amiodarone, diltiazem arrange for an electrocardiograph to exclude heart block
    • seek specialist advice.
  • Check serum electrolytes, urea, and creatinine one to two weeks after initiation, and one to two weeks after reaching the target dose.

Advice to patient

  • explain expected benefits - slow worsening of disease, improve symptoms and prolonged life-expectancy
  • there may be temporary deterioration in 20-30% of cases during titration
  • improvement in symptoms may happen slowly over three to six months
  • report any rapid deterioration in symptoms such as tiredness, fatigue or breathlessness
  • weigh themselves regularly and consult doctor if persistent weight gain (3 to 4lb or 1½ kg persisting over more than two days)
  • do not stop beta-blockers without consulting doctor.

Quick Reference Guide Review Date November 2011

Last Updated on Wednesday, 19 December 2012 12:24