What’s the Best Beta Blocker for Heart Failure?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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Beta blockers save lives after heart attack and improve mortality for heart failure patients. They also work well to control blood pressure. Carvedilol (Coreg was the brand name) has been known as the “heart failure beta blocker”—but now it appears that metoprolol (Lopressor) may share that title.

Many of my patients are asking: which is better? Let’s look at the recent evidence.

What’s the difference between carvedilol and metoprolol?
Carvedilol is known as a “non-selective beta blocker” meaning it blocks all beta receptors throughout the body. Metoprolol is known as a “selective beta blocker” and blocks primarily specific (β1) receptors which affect the heart, and heart rate. Why does this matter? Well you’d think you only want a medication that affects the heart, but carvedilol also inhibits β2 receptors and the effects of norepinephrine (similar to adrenaline) throughout the body. Turns out that’s important for heart failure.

Is carvedilol or metoprolol better for saving lives from heart failure?

Well, a JAMA (Journal of the American Medical Association) 2014 article looked at mortality rates in heart failure patients and found the effectiveness for prevention of death was similar for carvedilol and metoprolol. However, a very recent VA study found that metoprolol resulted in less frequent hospital admissions for heart failure, and that metoprolol had a slightly lower risk of death than carvedilol. I’d say they are about the same, or evidence tips in favor of metoprolol.

Which is better for survival after a heart attack?

They’re kind of the same. A recent 2015 study found that the risk of death or another heart attack was the same whether you were taking carvedilol or metoprolol.

What if I have diabetes?

The diabetes-friendly beta blockers are carvedilol and labetalol (Trandate). “Non-diabetes-friendly” beta blockers are metoprolol and atenolol (Tenormin).

The evidence is a little gray here. New diabetes diagnoses were more common in heart failure patients taking metoprolol than carvedilol. However, in a more recent study, the risk of diabetes for patients with high blood pressue was similar for carvedilol and other beta blockers like metoprolol. So, try to stick with carvedilol if you have diabetes but it’s not a must.

What about if I have COPD and heart failure?

You can take beta blockers if you have COPD (chronic obstructive pulmonary disease) and heart failure—although a recent study on patients with both found there was no survival benefit in folks taking carvedilol or metoprolol compared to non users. Hmmm.

Can either hurt my kidneys?

If you undergo a coronary angiogram, a contrast dye is used that may lead to kidney damage. One recent study found that carvedilol was better for kidney injury or “contrast induced nephropathy” after an angiogram than metoprolol.

These are both cheap, excellent generic medications with some subtle upsides for each. It’s a win win situation.

Dr O.

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