Beta-blockers for a weaker heart pump
Metoprolol succinate extended-release • carvedilol • bisoprolol
These medicines improve survival in HFrEF (a weak heart pump). Take one. Metoprolol means succinate extended-release, not tartrate. Bisoprolol is guideline-supported for HF; U.S. approval covers high blood pressure. [8] [7]
Benefits
Trials added medicine or placebo to usual care; do not rank drugs. [1] [2] [3]
| Medicine / study | Medicine | Placebo |
|---|---|---|
| Metoprolol ER · MERIT-HF (1 year) | 145/1,990 (7.3%) | 217/2,001 (10.8%) [1] |
| Carvedilol · COPERNICUS (10.4 months) | 130/1,156 (11.2%) | 190/1,133 (16.8%) [2] |
| Bisoprolol · CIBIS-II (1.3 years) | 156/1,327 (11.8%) | 228/1,320 (17.3%) [3] |
About 4, 6 and 6 fewer deaths per 100, respectively. Trials stopped early for benefit and predate modern treatment. [1] [2] [3]
Start slowly, avoid sudden stopping
Start when HF is stable. Your clinician raises doses gradually while checking pulse, blood pressure, fluid and symptoms. Metoprolol succinate ER/bisoprolol: once daily. Carvedilol tablets: twice daily with food. Do not crush or chew metoprolol ER. Sudden stopping can trigger chest pain or heart attack. Call about tiredness or dizziness before changing doses. [8] [5] [6]
Ask for your pulse/BP limits. Discuss heart block, pregnancy/breastfeeding and all medicines, including eye drops. Avoid carvedilol with asthma or severe liver disease. Monitor glucose if at risk: beta-blockers can hide low blood sugar’s fast heartbeat, especially when eating less/vomiting. [5] [6] [7]
Emergency help: severe breathing trouble, chest pain, fainting or face/throat swelling. Call promptly for wheezing, persistent dizziness, slow pulse with symptoms, worsening breathlessness, swelling, rapid weight gain or troublesome tiredness. [5] [6]
Reported problems
| Drug / event | Medicine | Placebo |
|---|---|---|
| Metoprolol: dizziness | 1.8% | 1.0% [5] |
| Metoprolol: slow pulse | 1.5% | 0.4% [5] |
| Carvedilol: dizziness | 24% | 17% [6] |
| Carvedilol: slow pulse | 10% | 3% [6] |
| Carvedilol: low BP | 14% | 8% [6] |
Same groups as benefits; metoprolol 1 year, carvedilol 10.4 months. Different reporting prevents safety ranking; comparable bisoprolol symptom rates unverified. [5] [6] [3]
Stopping
| Study / reason | Medicine | Placebo |
|---|---|---|
| MERIT-HF: any cause; 1 year | 279/1,990 (14.0%) | 310/2,001 (15.5%) [4] |
| MERIT-HF: adverse event | 196/1,990 (9.8%) | 234/2,001 (11.7%) [4] |
| CIBIS-II: any reason; 1.3 years | 194/1,327 (14.6%) | 192/1,320 (14.5%) [3] |
| COPERNICUS: excluding death; estimated at 1 year | 14.8% | 18.5% [2] |
A Norwegian refill study estimated 58% remained supplied at two years, allowing gaps up to 30 days; this does not measure side-effect stopping. [9]
Costs
| Payment route | Price and conditions |
|---|---|
| GoodRx coupon cash | Metoprolol succinate ER 25 mg ×90: $15.75; carvedilol 12.5 mg ×180: $20.85; bisoprolol 5 mg ×30: $9.00. [10] [11] [12] |
| Blueberry cash | Same products; nonmember, fees included: $18.45 / $18.70 / $12.07; individually shipped: $22.44 / $22.69 / $16.06. [13] [14] |
| Insured benchmark | Employer-plan tier 1/2/3 copays average $12/$40/$71 (KFF 2025, 3+ tiers); not these drugs’ copays. [15] |
At 1, 2 and 1 tablets/day: 90, 90 and 30 days, respectively. Verify pharmacy/manufacturer price, tier and deductible. [10] [11] [12] [13]
Medicare Part D 2026: plan-specific costs; deductible up to $615, annual out-of-pocket cap $2,100 for covered drugs, excluding premiums. Extra Help may lower costs. Cash outside Part D does not count toward its deductible/cap. [16] [17] [18]