Evidence-based beta-blockers (bisoprolol, carvedilol, metoprolol succinate CR/XL, nebivolol)

FMT in HFrEF · Class I

Removal by dialysis

What each drug's prescribing information says about removal by (haemo)dialysis. Where the label is silent, this page says so rather than inferring from protein binding.

BisoprololNot removed (or not meaningfully removed)
- “Since limited data suggest that bisoprolol fumarate is not dialyzable, drug replacement is not necessary in patients undergoing dialysis.”
  Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· DOSAGE AND ADMINISTRATION, Patients with Renal or Hepatic Impairment Source
CarvedilolNot removed (or not meaningfully removed)
- “Consistent with its high degree of plasma protein‑binding, carvedilol does not appear to be cleared significantly by hemodialysis.”
  COREG (carvedilol) PI, Waylis (2026)· 12.4 Specific Populations, Renal Impairment Source
Metoprolol succinate (CR/XL)Not removed (or not meaningfully removed)
- “Hemodialysis is unlikely to make a useful contribution to metoprolol elimination”
  TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 10 OVERDOSAGE Source
NebivololNot removed (or not meaningfully removed)
- “Because of extensive drug binding to plasma proteins, hemodialysis is not expected to enhance nebivolol clearance.”
  BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· OVERDOSAGE Source
- “No studies have been conducted in patients on dialysis”
  BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· 12.4 Specific Populations Source

Drugs and doses

Drug	Brands	Start	Target	Kidney dosing
Bisoprolol	Zebeta (US, discontinued brand), Cardicor, Concor, Congescor	1.25 mg o.d.	10 mg o.d.	US label (hypertension only; no US HF indication): if CrCl <40 mL/min, start at 2.5 mg and titrate cautiously; label says limited data suggest it is not dialyzable, so no supplemental dose after dialysis. A 2018 crossover PK trial (Tieu) found bisoprolol IS substantially dialyzable. UK HF SmPC (Cardicor) has no PK data in HF with renal impairment, says to uptitrate with additional caution, and reports no therapeutic experience in HF with severely impaired renal function. The ESC HF start dose of 1.25 mg is already below the US renal start dose.
Carvedilol	Coreg, Coreg CR, Eucardic	3.125 mg b.i.d.	25 mg b.i.d. (50 mg b.i.d. if >85 kg)	No renal dose adjustment in the US label. Plasma levels are about 40-50% higher in moderate-severe renal impairment but with similar ranges; not significantly cleared by haemodialysis. The label warns of rare deterioration of renal function in HF, with risk in SBP <100 mmHg, ischaemic or diffuse vascular disease, or underlying renal insufficiency: monitor renal function during up-titration and reduce or stop if it worsens. The only RCT in dialysis patients with HF (Cice 2003) used carvedilol.
Metoprolol succinate (CR/XL)	Toprol-XL, Beloc-Zok	12.5–25 mg o.d.	200 mg o.d.	US label: no dose reduction needed in chronic renal failure. The label says haemodialysis is unlikely to contribute usefully to elimination, but modern high-flux HD clears metoprolol extensively (Tieu 2018: 87 mL/min). Mullens 2022 says the dose may need adjusting in dialysis.
Nebivolol	Bystolic (US), Nebilet	1.25 mg o.d.	10 mg o.d.	US label (hypertension only; no US HF indication): if CrCl <30 mL/min, start at 2.5 mg and titrate slowly; not studied in dialysis. Highly protein-bound, so HD is not expected to enhance clearance. EU/UK SmPC (HF indication, age ≥70, from SENIORS): no adjustment in mild-moderate renal insufficiency; not recommended in severe renal insufficiency (serum creatinine ≥250 µmol/L, about ≥2.8 mg/dL), with no experience in that group. EU/UK contraindications also include pre-treatment HR <60 bpm and SBP <90 mmHg.

Status by kidney stage

Stage	Initiate	Continue
G1	Recommended Class I in stable symptomatic HFrEF. Start low once the patient is stable and euvolaemic, then uptitrate to target or highest tolerated dose.	Recommended Continue lifelong at the highest tolerated dose, even if symptoms or LVEF improve.
G2	Recommended Same as without CKD: Class I in stable symptomatic HFrEF, with no renal dose adjustment.	Recommended Continue at the highest tolerated dose.
G3a	Recommended ESC CVD-CKD 2026 gives Class I at eGFR ≥30. In the IPD meta-analysis, mortality benefit in sinus rhythm was preserved at eGFR 45-59 (HR 0.73).	Recommended Continue. Beta-blockers do not cause an acute or long-term eGFR decline.
G3b	Recommended Class I at eGFR ≥30 (ESC CVD-CKD 2026). Mortality benefit in sinus rhythm at eGFR 30-44 (HR 0.71). Bisoprolol US label: start at 2.5 mg if CrCl <40, but the ESC HF start dose of 1.25 mg is lower anyway.	Recommended Continue. Discontinuation for renal impairment was similar to placebo in trials.
G4	Use with caution ESC CVD-CKD 2026: 'may be considered' (Class IIb, Level C) at eGFR 15-29. Benefit is uncertain because of too few patients in trials. Start low and titrate slowly. Nebivolol: start at 2.5 mg if CrCl <30 (US); EU SmPC says not recommended if creatinine ≥250 µmol/L.	Allowed Can be continued: beta-blockers are safe at low eGFR, and other indications (arrhythmia, rate control) often apply. No renal stopping rule.
G5	No data No data: no trial evidence below eGFR 15 (Beldhuis 2022: no data in CKD stage 5); the ESC CVD–CKD recommendation covers eGFR ≥15 (IIb at 15–29); KDIGO 2026 still lists a beta-blocker at eGFR <15. Individualize with nephrology input.	Allowed Continuation is reasonable (safe at low eGFR; rate and rhythm indications), with HR and BP monitoring.
dialysis	Use with caution Can be started in stable dialysis patients with HFrEF. The only RCT (Cice 2003, n=114, carvedilol) showed lower 2-year mortality. Prefer an agent with low dialytic clearance (carvedilol). Watch for bradycardia and intradialytic hypotension, especially after dose increases (BLOCADE feasibility).	Use with caution Continue. Check pre- and post-dialysis HR and BP. Dialytic clearance of metoprolol (and, per the 2018 PK trial, bisoprolol) may lower drug levels after HD. Nebivolol has not been studied in dialysis.
aki	Use with caution There is no kidney-function bar to starting, but defer until the patient is haemodynamically stable and euvolaemic. AKI often accompanies decompensation, where new starts are contraindicated if IV inotropes are needed or shock is present.	Use with caution AKI alone is not a reason to stop: ESC lists RAASi, MRA and SGLT2i (not beta-blockers) for temporary discontinuation in AKI. Hold or halve only for severe haemodynamic instability, cardiogenic shock, symptomatic bradycardia or hypotension. Carvedilol label: reduce or stop if renal function worsens in at-risk patients.
transplant	Use with caution No HF-specific data in kidney transplant recipients; use the eGFR-stage column. Carvedilol raises cyclosporine levels, so monitor cyclosporine closely after starting.	Allowed No transplant-specific restriction. Continue per eGFR stage and haemodynamics.

Cutoffs recorded from the sources

hr < 50 b.p.m. → caution (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Current or recent (<4 weeks) exacerbation of HF (e.g. hospital admission with worsening HF), heart block, or heart rate <50 b.p.m.” — esc2026-supp, p. 14
hr < 50 b.p.m. → dose-reduce if symptomatic; stop if severe deterioration (dose_reduce; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“If <50 b.p.m. and worsening symptoms, lower dose of beta-blocker, or, if severe deterioration, stop beta-blocker (rarely necessary).” — esc2026-supp, p. 15
hr < 55 b.p.m. → dose-reduce (dose_reduce; carvedilol)
“The dose of COREG should be reduced if patients experience bradycardia (heart rate less than 55 beats per minute).” — fda-carvedilol, 2.1 Heart Failure
hr < 55 b.p.m. → dose-reduce if <50-55 at rest or symptomatic (dose_reduce; nebivolol)
“Beta-adrenergic antagonists may induce bradycardia: if the pulse rate drops below 50-55 bpm at rest and/or the patient experiences symptoms that are suggestive of bradycardia, the dosage should be reduced.” — smpc-nebivolol, 4.4 Special warnings and precautions
hr < 60 b.p.m. → contraindicated (initiate; nebivolol)
“bradycardia (heart rate < 60 bpm prior to start therapy).” — smpc-nebivolol, 4.3 Contraindications
hr > 60 b.p.m. → uptitration permitted (with no symptomatic hypotension) (uptitrate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“HR >60 bpm • No symptomatic hypotension” — esc2026-ckd, p. 43
hr < 50 b.p.m. → perform ECG; review other HR-slowing drugs (hold; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Low HR (<50 b.p.m.): perform ECG, consider stopping other HR-slowing drugs, take adequate measures if high degree artrioventricular block.” — esc2026-ckd, p. 43
hr >= 70 b.p.m. → after beta-blocker at target/maximally tolerated dose, consider adding ivabradine (sinus rhythm, LVEF ≤35%) (uptitrate; ivabradine-add-on)
“As beta-blockers have well-proven morbidity and mortality benefits, they should be initiated and uptitrated to target doses first, before assessing the resting heart rate for consideration of adding ivabradine.” — esc2026, p. 34
sbp < 90 mmHg → caution (relieve congestion/achieve euvolaemia first; seek specialist advice) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“If persisting signs of congestion, hypotension (systolic <90 mmHg), raised jugular venous pressure, ascites, marked peripheral oedema—try” — esc2026-supp, p. 14
sbp < 90 mmHg → contraindicated (initiate; nebivolol)
“hypotension (systolic blood pressure < 90 mmHg).” — smpc-nebivolol, 4.3 Contraindications
sbp < 100 mmHg → monitor renal function during up-titration; reduce/stop if renal function worsens (continue; carvedilol)
“Patients at risk appear to be those with low blood pressure (systolic blood pressure less than 100 mm Hg), ischemic heart disease and diffuse vascular disease, and/or underlying renal insufficiency.” — fda-carvedilol, 5.8 Deterioration of Renal Function
egfr >= 30 mL/min/1.73m2 → recommended (Class I, Level A) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Treatment with a beta-blocker is recommended in patients with HFrEF and CKD with an eGFR ≥30 mL/min/1.73 m2 to reduce the risk of HF hospitalization and death.” — esc2026-ckd, p. 39
egfr < 30 mL/min/1.73m2 → caution (may be considered, Class IIb, Level C, for eGFR 15-29) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Treatment with a beta-blocker may be considered in patients with HFrEF and CKD with an eGFR 15–29 mL/min/1.73 m2” — esc2026-ckd, p. 40
egfr < 15 mL/min/1.73m2 → no trial data (caution) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“No data currently exist for β-blocker therapy in patients with HFrEF with CKD stage 5 for either end point.” — beldhuis2022, p. 11
egfr < 40 mL/min (creatinine clearance) → initial dose 2.5 mg; cautious titration (US hypertension label) (dose_reduce; bisoprolol)
“In patients with hepatic impairment (hepatitis or cirrhosis) or renal dysfunction (creatinine clearance less than 40 mL/min), the initial daily dose should be 2.5 mg and caution should be used in dose-titration.” — fda-bisoprolol, DOSAGE AND ADMINISTRATION: Patients with Renal or Hepatic Impairment
egfr < 30 mL/min (creatinine clearance) → initial dose 2.5 mg; titrate slowly (US hypertension label) (dose_reduce; nebivolol)
“In patients with severe renal impairment (ClCr less than 30 mL/min) the recommended initial dose is 2.5 mg once daily; titrate up slowly if needed. BYSTOLIC has not been studied in patients receiving dialysis [see Clinical Pharmacology ( 12.4 ) ].” — fda-nebivolol, 2.1 Dosage: Renal Impairment
creatinine_abs >= 250 µmol/L (≈2.83 mg/dL) → not-recommended (initiate; nebivolol)
“There is no experience in patients with severe renal insufficiency (serum creatinine ≥ 250µmol/L). Therefore, the use of Nebivolol in these patients is not recommended.” — smpc-nebivolol, 4.2 Posology: Chronic heart failure, Patients with renal insufficiency
other < 14 days since temporary discontinuation → restart directly at previously tolerated dose if stable and euvolaemic (continue; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“If beta-blocker therapy has been temporarily discontinued for less than 14 days, it should, in most cases, be safe to initiate directly at the previously tolerated doses in stable patients.” — esc2026-supp, p. 15
other >= 2 weeks between dose doublings (outpatient, not closely monitored) → minimum uptitration interval (uptitrate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“In those patients where close monitoring is not possible, dose should be doubled at not less than 2-week intervals (slower uptitration may be needed in some patients).” — esc2026-supp, p. 15
other < 4 weeks since HF exacerbation → caution / seek specialist advice (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Current or recent (<4 weeks) exacerbation of HF (e.g. hospital admission with worsening HF), heart block, or heart rate <50 b.p.m.” — esc2026-supp, p. 14
other > 85 kg body weight → carvedilol target may be 50 mg b.i.d. (uptitrate; carvedilol)
“A maximum dose of 50 mg twice daily has been administered to patients with mild-to-moderate heart failure weighing over 85 kg (187 lbs.).” — fda-carvedilol, 2.1 Heart Failure

Trial evidence (informational)

CIBIS-II (bisoprolol) · NYHA III-IV, LVEF ≤35%, n=2647
All-cause mortality: HR 0.66 (95% CI 0.54-0.81)
“All-cause mortality was significantly lower with bisoprolol than on placebo (156 [11.8%] vs 228 [17.3%] deaths with a hazard ratio of 0.66 (95% CI 0.54-0.81, p<0.0001).” — cibis2-1999, Abstract
MERIT-HF (metoprolol CR/XL) · NYHA II-IV, LVEF ≤40%, n=3991
All-cause mortality: RR 0.66 (95% CI 0.53-0.81); 34% reduction
“The trial was terminated early for a statistically significant reduction in all-cause mortality (34%, nominal p= 0.00009).” — fda-metoprolol-succinate, 14.3 Heart Failure
COPERNICUS (carvedilol) · Severe HF, LVEF <25%, n=2289
All-cause mortality: HR 0.65 (95% CI 0.52-0.81)
“The trial was stopped after a median follow-up of 10 months because of an observed 35% reduction in mortality (from 19.7% per patient-year on placebo to 12.8% on carvedilol; hazard ratio 0.65, 95% CI: 0.52 to 0.81, P = 0.0014, adjusted) (see Figure 1).” — fda-carvedilol, 14.1 Heart Failure: Severe Heart Failure (COPERNICUS)
SENIORS (nebivolol) · Age ≥70, HF hospitalization in prior year or LVEF ≤35%, n=2128
All-cause mortality or CV hospital admission (death alone not significant): HR 0.86 (95% CI 0.74-0.99); death HR 0.88 (0.71-1.08)
“The primary outcome occurred in 332 patients (31.1%) on nebivolol compared with 375 (35.3%) on placebo [hazard ratio (HR) 0.86, 95% CI 0.74-0.99; P=0.039].” — flather2005, Abstract
BB-meta-HF IPD (Kotecha 2014) · 10 RCTs, n=18,254; sinus rhythm vs AF
All-cause mortality: Sinus rhythm HR 0.73 (0.67-0.80); AF HR 0.97 (0.83-1.14)
“β-blocker therapy led to a significant reduction in all-cause mortality in patients with sinus rhythm (hazard ratio 0·73, 0·67-0·80; p<0·001), but not in patients with atrial fibrillation (0·97, 0·83-1·14; p=0·73), with a significant p value for interaction of baseline rhythm (p=0·002).” — kotecha2014, Abstract
BB-meta-HF IPD by LVEF (Cleland 2018) · 11 RCTs, sinus rhythm, LVEF 40-49% subgroup n=575
CV death (LVEF 40-49%): HR 0.48 (95% CI 0.24-0.97); all-cause HR 0.59 (0.34-1.03)
“Cardiovascular death occurred in 13/292 [4.5%] with beta-blockers and 26/283 [9.2%] with placebo; adjusted HR 0.48 (95% CI 0.24-0.97).” — cleland2018, Abstract
BB-meta-HF IPD by eGFR (Kotecha 2019) · 10 RCTs, LVEF <50%, sinus rhythm, n=13,861
All-cause mortality: eGFR 45-59: HR 0.73 (0.62-0.86); eGFR 30-44: HR 0.71 (0.58-0.87)
“In 13,861 patients in sinus rhythm, beta-blockers reduced mortality versus placebo; adjusted hazard ratio (HR): 0.73 for eGFR 45 to 59 ml/min/1.73 m2 (95% CI: 0.62 to 0.86; p < 0.001) and 0.71 for eGFR 30 to 44 ml/min/1.73 m2 (95% CI: 0.58 to 0.87; p = 0.001).” — kotecha2019, Abstract
Cice 2003 (carvedilol in dialysis) · Dialysis + dilated cardiomyopathy, n=114
2-year all-cause mortality: 51.7% vs 73.2% (p<0.01)
“At two years, 51.7% of the patients died in the carvedilol group, compared with 73.2% in the placebo group (p < 0.01).” — cice2003, Abstract
ESC 2026 summary · HFrEF
Death: Bisoprolol, metoprolol succinate, carvedilol reduce death; nebivolol only the composite
“Bisoprolol, sustained-release metoprolol (succinate), and carvedilol have been shown to reduce the risk of death in patients with HFrEF, whereas nebivolol only reduced the combined endpoint of all-cause mortality and CV hospitalization.” — esc2026, p. 34
ESC 2026 summary (LVEF 40-50%) · HFrEF/HFmrEF in sinus rhythm
CV and all-cause mortality: Similar reductions at LVEF <40% and 40-50%
“An individual patient meta-analysis of RCTs of beta-blockers suggested similar reductions in CV and all-cause mortality for patients in sinus rhythm with HFrEF who had LVEF <40% and LVEF 40%–50%.” — esc2026, p. 34

Acute kidney injury

No guideline gives a kidney-function hold rule for beta-blockers in AKI. ESC 2026 limits AKI-driven temporary discontinuation to MRA/ARNI/ACE-I/ARB/SGLT2-I, and stops beta-blockers only for severe haemodynamic instability. Do not start new beta-blockers during decompensation or shock; start once stable and euvolaemic. If WRF occurs during uptitration without a BP drop, suspect worsening HF. Carvedilol label: reduce or stop if renal function worsens in patients with SBP <100, vascular disease or renal insufficiency.

“Temporary discontinuation of beta-blockers and ARNIs/ACE-Is/ARBs is advised in patients with severe haemodynamic instability.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source
“Importantly, misinterpretation of changes in kidney function, leading to inappropriate discontinuation or down-regulation of doses of FMT, is a leading cause of insufficient FMT and should be avoided, both in decompensated and chronic HF.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source
“In patients experiencing mild decrease of renal function or asymptomatic reduction of blood pressure during HF hospitalization, diuresis and other GDMT should not routinely be discontinued (6-11).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 80 Source
“Usually beta-blocker do not cause drop in eGFR but a drop in blood pressure is expected which can result in a drop in eGFR.”
Beldhuis 2022 Circulation: Evidence-based medical therapy in HFrEF patients with CKD (2022)· p. 8 Source

Dialysis

One small RCT supports carvedilol in dialysis patients with dilated cardiomyopathy (Cice 2003: 2-year mortality 51.7% vs 73.2%). BLOCADE (carvedilol vs placebo) could not recruit; 68% tolerated run-in, with bradycardia/hypotension withdrawals and more intradialytic hypotension after dose increases. HDPAL (hypertensive HD patients with LVH) found fewer CV events with atenolol than lisinopril, but atenolol is not an HF beta-blocker. Dialyzability is disputed: carvedilol has negligible dialytic clearance (all sources agree); metoprolol is extensively dialyzed (Tieu 2018) despite its label; bisoprolol is called non- or low-dialysable by its label and ESC CVD-CKD but was dialyzable in Tieu 2018. Observational mortality data by dialyzability conflict. Practical default: carvedilol first in dialysis; give metoprolol after the HD session; avoid nebivolol (not studied).

Trials: Cice 2003 (carvedilol vs placebo, n=114, dialysis + DCM), BLOCADE feasibility (carvedilol vs placebo, n=72 run-in, 49 randomized), HDPAL (atenolol vs lisinopril, n=200, HD + LVH + hypertension), Tieu 2018 (4-way PK crossover, n=8, high-flux HD)

“CONCLUSIONS: Carvedilol reduced morbidity and mortality in dialysis patients with dilated cardiomyopathy.”
Cice G et al. Carvedilol increases two-year survival in dialysis patients with dilated cardiomyopathy. J Am Coll Cardiol 2003 (PMID 12742278, abstract) (2003)· Abstract Source
“49 of 72 run-in participants (68%; 95% CI, 57%-79%) achieved the primary outcome. 5 of the 23 withdrawals from run-in were attributable to bradycardia or hypotension.”
Roberts MA et al. BLOCADE Feasibility Study. Am J Kidney Dis 2016 (PMID 26717861, abstract) (2016)· Abstract Source
“Overall, there were 4 IDH events per 100 hemodialysis sessions; in participants allocated to carvedilol versus placebo, respectively, there were 7 versus 2 IDH events per 100 hemodialysis sessions (P=0.1) in the 2 weeks immediately following a dose increase and 4 versus 3 IDH events per 100 hemodialysis sessions after no dose increase (P=0.7).”
Roberts MA et al. BLOCADE Feasibility Study. Am J Kidney Dis 2016 (PMID 26717861, abstract) (2016)· Abstract Source
“Among maintenance dialysis patients with hypertension and left ventricular hypertrophy, atenolol-based antihypertensive therapy may be superior to lisinopril-based therapy in preventing cardiovascular morbidity and all-cause hospitalizations.”
Agarwal R et al. Atenolol or lisinopril in hemodialysis (HDPAL). Nephrol Dial Transplant 2014 (PMID 24398888, abstract) (2014)· Abstract Source
“Using the recovery clearance method, the dialytic clearance values for atenolol, metoprolol, bisoprolol, and carvedilol were 72, 87, 44, and 0.2 ml/min, respectively (P<0.001).”
Tieu A et al. Beta-blocker dialyzability in maintenance hemodialysis: randomized PK trial. Clin J Am Soc Nephrol 2018 (PMID 29519953, abstract) (2018)· Abstract Source
“Initiation of a high- versus low-dialyzability β-blocker was associated with a higher risk of death in the following 180 days (relative risk, 1.4; 95% confidence interval, 1.1 to 1.8; P<0.01).”
Weir MA et al. Beta-blocker dialyzability and mortality in older hemodialysis patients. J Am Soc Nephrol 2015 (PMID 25359874, abstract) (2015)· Abstract Source
“Pooled data suggest highly dialyzable β-blockers are associated with similar mortality events and fewer cardiovascular events compared with poorly dialyzable β-blockers.”
Tella A, et al. Beta-blocker use and cardiovascular outcomes in hemodialysis: a systematic review. Kidney Med 2022;4:100460 (PubMed abstract, PMID 35539430) (2022)· Abstract Source
“Intradialytic hypotension was more common in those on carvedilol (a poorly dialyzable β-blocker) compared with those on metoprolol (a highly dialyzable β-blocker; adjusted incidence rate ratio, 1.10; 95% CI, 1.09-1.11).”
Tella A, et al. Beta-blocker use and cardiovascular outcomes in hemodialysis: a systematic review. Kidney Med 2022;4:100460 (PubMed abstract, PMID 35539430) (2022)· Abstract Source
“The use of dialyzable and non-dialyzable beta-blockers had no impact on the risk of all-cause mortality, overall MACE, and AMI among dialysis patients.”
Yeh TH, et al. Impact of type of dialyzable beta-blockers on subsequent risk of mortality in patients receiving dialysis: a systematic review and meta-analysis. PLoS One 2022;17:e0279680 (PubMed abstract, PMID 36584227) (2022)· Abstract Source
“The use of β-blockers was associated with a reduced risk of heart failure-related mortality in the PD population.”
Gao M, et al. Association between beta-blocker utilization and heart failure mortality in the peritoneal dialysis population: a cohort study. Clin Kidney J 2024;17:sfae022 (PubMed abstract, PMID 38444751) (2024)· Abstract Source
“Consistent with its high degree of plasma protein‑binding, carvedilol does not appear to be cleared significantly by hemodialysis.”
COREG (carvedilol) PI, Waylis (2026)· 12.4 Specific Populations: Renal Impairment Source
“Since limited data suggest that bisoprolol fumarate is not dialyzable, drug replacement is not necessary in patients undergoing dialysis.”
Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· DOSAGE AND ADMINISTRATION: Patients with Renal or Hepatic Impairment Source
“Renal clearance of nebivolol is decreased in patients with severe renal impairment. BYSTOLIC has not been studied in patients receiving dialysis [see Clinical Pharmacology ( 12.4 ) and Dosage and Administration ( 2.1 )].”
BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· Warnings and Precautions: Impaired Renal Function Source
“Unlike the RAAS inhibitor trials, many RCTs have included patients with eGFR as low as 15 mL/min/1.73 m2 and, in one small trial, patients on dialysis.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 36 Source

Kidney transplant

No HF-specific data in kidney transplant recipients. Apply the recipient's eGFR stage. Carvedilol raises trough cyclosporine (about 30% of renal transplant subjects needed a ~20% lower cyclosporine dose), so monitor calcineurin-inhibitor levels after starting carvedilol. KDIGO 2021 found no outcome effect of beta-blockers as antihypertensives in transplant recipients (CCB/ARB preferred for hypertension; not HF-specific).

“In about 30% of subjects, the dose of cyclosporine had to be reduced in order to maintain cyclosporine concentrations within the therapeutic range, while in the remainder no adjustment was needed.”
COREG (carvedilol) PI, Waylis (2026)· 7.3 Cyclosporine Source
“Recommendation 4.1: We recommend that a dihydropyridine calcium channel blocker (CCB) or an ARB be used as the first-line antihypertensive agent in adult kidney transplant recipients (1C).”
KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in CKD (2021)· p. 30 (summary of recommendations; also Chapter 4, p. 60) Source

Albuminuria

No source gives albuminuria-dependent guidance for beta-blockers in HF. Beta-blockers are not albuminuria-lowering agents. KDIGO 2026 advises ACEi/ARB for CKD with diabetes or proteinuria irrespective of HF status, which does not affect beta-blocker use.

No verbatim statement found for this cell.

Monitoring

Check HR, BP, symptoms and congestion signs (weight) at each start or uptitration. Labs are not needed specifically for beta-blockers, except renal function for carvedilol in at-risk patients (SBP <100, vascular disease, renal insufficiency) and digoxin levels when combined with carvedilol. ECG for bradycardia to exclude heart block. Patients should weigh themselves daily during titration.

“Monitor heart rate, blood pressure, and clinical status (symptoms, signs—especially signs of congestion, body weight).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source
“Titrate BB to maximal dose • Monitor BP and HR”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 43 Source
“Monitor heart rate in patients receiving TOPROL-XL. If severe bradycardia develops, reduce or stop TOPROL- XL.”
TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 5.4 Bradycardia Source
“Uptitration of FMT at least every 1–2 weeks in patients with HF, guided by symptoms, vital signs, and laboratory findings, to achieve optimal target doses shown to be efficacious in RCTs is recommended to reduce the risk of HFH or death.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 11 (summary of recommendations; same text in Recommendation Table 5, p. 37) Source

In-hospital initiation

Continue existing beta-blockers during HF admission unless there is severe haemodynamic instability or cardiogenic shock (AHA, ESC). Start new beta-blockers cautiously in hospital once haemodynamically stable and decongested, ideally before discharge. Not during IV inotropes: the carvedilol and bisoprolol (EU) labels contraindicate decompensated HF requiring IV inotropes, and the metoprolol and nebivolol labels contraindicate decompensated HF outright. Rapid uptitration is acceptable in hospital or under close monitoring (STRONG-HF strategy).

“In patients admitted with DHF, beta-blockers should be cautiously initiated in hospital, once the patient is haemodynamically stabilized.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“In patients hospitalized with DHF/WHF—after stabilizing, relieving congestion, and, if possible, restoring 'euvolaemia' (but ideally before discharge).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 14 Source
“In patients with HFrEF requiring hospitalization, preexisting GDMT should be continued and optimized to improve outcomes, unless contraindicated (1-5).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 80 Source
“Patients with cardiogenic shock or who have decompensated heart failure requiring the use of intravenous inotropic therapy. Such patients should first be weaned from intravenous therapy before initiating COREG.”
COREG (carvedilol) PI, Waylis (2026)· 4 Contraindications Source

Outpatient

Start early in stable outpatients at a low dose and double no more often than every 2 weeks (labels: at least 2-week intervals), aiming for target or highest tolerated dose. Some beta-blocker is better than none. If congestion increases, raise the diuretic first, then halve the beta-blocker if needed. Asymptomatic low BP needs no change. Do not stop abruptly.

“Beta-blockers should be initiated early in clinically stable patients, at low doses and gradually uptitrated to the highest tolerated dose.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“The recommended starting dose of COREG is 3.125 mg twice daily for 2 weeks. If tolerated, patients may have their dose increased to 6.25, 12.5, and 25 mg twice daily over successive intervals of at least 2 weeks.”
COREG (carvedilol) PI, Waylis (2026)· 2.1 Heart Failure Source
“If increasing congestion, increase dose of diuretic or halve a dose of beta-blocker (if increasing diuretic dose does not work).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source
“Beta-blockers should not be stopped suddenly unless absolutely necessary (there is a risk of a 'rebound' increase in myocardial ischaemia or infarction and arrhythmias).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source

Where sources disagree

Dialyzability of metoprolol and bisoprolol (agent choice in haemodialysis)

“Hemodialysis is unlikely to make a useful contribution to metoprolol elimination [see Clinical Pharmacology (12.3)].”
TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 10 Overdosage Source
“Since limited data suggest that bisoprolol fumarate is not dialyzable, drug replacement is not necessary in patients undergoing dialysis.”
Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· DOSAGE AND ADMINISTRATION: Patients with Renal or Hepatic Impairment Source
“Depending on drug kinetics, dose adjustment may be required for some beta-blockers (e.g. atenolol, nadolol) but not others (e.g. bisoprolol, metoprolol, carvedilol), and low-dialysability beta-blockers (i.e. bisoprolol or propranolol) may be preferred to avoid under-treatment.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 48 Source
“Atenolol and metoprolol are extensively cleared by hemodialysis compared with the negligible dialytic clearance of carvedilol. Contrary to estimates of dialyzability on the basis of previous literature, our data indicate that bisoprolol is also dialyzable.”
Tieu A et al. Beta-blocker dialyzability in maintenance hemodialysis: randomized PK trial. Clin J Am Soc Nephrol 2018 (PMID 29519953, abstract) (2018)· Abstract Source
“Nevertheless, it is important to remember that carvedilol is not dialyzable (and bisoprolol and nebivolol to a limited extent) while more water soluble beta-blockers (being metoprolol and atenolol) are removed by dialysis, so dose of metoprolol might need to be adjusted (atenolol is not advised in HF).”
Mullens 2022 EJHF: Renal effects of GDMT in HF, HFA/ESC consensus statement (2022)· p. 8 Source
“Initiation of a high- versus low-dialyzability β-blocker was associated with a higher risk of death in the following 180 days (relative risk, 1.4; 95% confidence interval, 1.1 to 1.8; P<0.01).”
Weir MA et al. Beta-blocker dialyzability and mortality in older hemodialysis patients. J Am Soc Nephrol 2015 (PMID 25359874, abstract) (2015)· Abstract Source
“Pooled data suggest highly dialyzable β-blockers are associated with similar mortality events and fewer cardiovascular events compared with poorly dialyzable β-blockers.”
Tella A, et al. Beta-blocker use and cardiovascular outcomes in hemodialysis: a systematic review. Kidney Med 2022;4:100460 (PubMed abstract, PMID 35539430) (2022)· Abstract Source

Tool uses tieu2018: Labels (higher authority) say metoprolol and bisoprolol need no dialysis adjustment, but their dialyzability statements rest on older low-flux data. The only modern high-flux PK RCT (Tieu 2018) shows metoprolol and bisoprolol are dialyzable and carvedilol is not. Carvedilol's negligible HD clearance is undisputed (label, ESC CVD-CKD, Mullens, Tieu) and it is the only beta-blocker with RCT outcome data in dialysis (Cice 2003). Proposal: in the dialysis cell, suggest carvedilol first; for metoprolol, give after HD; do not describe bisoprolol as low-dialysability. Mortality impact of dialyzability is unresolved (Weir 2015 vs Tella/Yeh 2022 meta-analyses). Owner decision.

Beta-blockers at eGFR 15-29 and <15 (G4/G5)

“Treatment with a beta-blocker may be considered in patients with HFrEF and CKD with an eGFR 15–29 mL/min/1.73 m2”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 40 Source
“<15 15–29 30–59 ≥60 • ß-blocker • Hydralazine/ nitrates”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 11
“In contrast, in CKD stage 4, there was also no clear benefit of β-blocker therapy (Figure S5A), but also no evidence of harm.”
Beldhuis 2022 Circulation: Evidence-based medical therapy in HFrEF patients with CKD (2022)· p. 11 Source
“Due to exclusion criteria, there were insufficient patients with severe renal dysfunction (eGFR <30 ml/min/1.73 m2) to draw conclusions.”
Kotecha D, et al. Impact of renal impairment on beta-blocker efficacy in patients with heart failure. J Am Coll Cardiol 2019;74:2893-904 (PubMed abstract, PMID 31806133) (2019)· Abstract Source
“Even in most patients with CKD the initiation of beta-blockers, ACE-Is/ARNIs/ARBs, SGLT2-Is, and MRAs is recommended.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66 Source

Tool uses esc2026-ckd: No FDA label sets an eGFR floor for carvedilol or metoprolol, so the guideline governs. ESC CVD-CKD 2026 is the most specific guideline: Class I at ≥30, IIb at 15-29, silent below 15. KDIGO 2026 (conference figure) still lists beta-blocker at <15. Proposal: G4 initiate = caution, G5 initiate = caution (no data), continue = allowed at both (Beldhuis: safe; other indications). Nebivolol drug-level flag: not recommended at serum creatinine ≥250 µmol/L (EU SmPC, its only HF label).

Decompensated HF: labelled contraindication vs guideline continuation/in-hospital initiation

“TOPROL-XL is contraindicated in severe bradycardia, second- or third-degree heart block, cardiogenic shock, decompensated heart failure, sick sinus syndrome (unless a permanent pacemaker is in place), and in patients who are hypersensitive to any component of this product.”
TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 4 Contraindications Source
“Patients with cardiogenic shock or who have decompensated heart failure requiring the use of intravenous inotropic therapy. Such patients should first be weaned from intravenous therapy before initiating COREG.”
COREG (carvedilol) PI, Waylis (2026)· 4 Contraindications Source
“In patients admitted with DHF, beta-blockers should be cautiously initiated in hospital, once the patient is haemodynamically stabilized.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“Temporary discontinuation of beta-blockers and ARNIs/ACE-Is/ARBs is advised in patients with severe haemodynamic instability.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source
“In patients with HFrEF requiring hospitalization, preexisting GDMT should be continued and optimized to improve outcomes, unless contraindicated (1-5).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 80 Source

Tool uses fda-carvedilol: Label > guideline for initiation: do not start a beta-blocker in decompensated/unstable HF, cardiogenic shock, or while on IV inotropes. Start once stabilized and decongested (ESC wording matches the carvedilol label's 'weaned from IV therapy' condition). For patients already on a beta-blocker, follow ESC/AHA: continue, possibly at reduced dose, unless severe haemodynamic instability or shock. The metoprolol label's blanket 'decompensated heart failure' contraindication is read as applying to new starts.

Heart-rate cutoff for caution / dose reduction

“If <50 b.p.m. and worsening symptoms, lower dose of beta-blocker, or, if severe deterioration, stop beta-blocker (rarely necessary).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source
“If pulse rate drops below 55 beats per minute, the dosage should be reduced.”
COREG (carvedilol) PI, Waylis (2026)· 5.2 Bradycardia Source
“bradycardia (heart rate < 60 bpm prior to start therapy).”
Nebivolol 5 mg tablets, UK SmPC, Amarox Limited (emc); Nebilet-equivalent text incl. CHF indication (2025)· 4.3 Contraindications Source
“HR >60 bpm • No symptomatic hypotension”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 43 Source

Tool uses fda-carvedilol: Use per-drug label values where they exist (carvedilol reduce if <55; nebivolol EU: do not start if <60). Otherwise use the ESC 2026 Table S6 class default (<50 b.p.m. = caution / reduce if symptomatic). Use ESC CVD-CKD Fig. 11 (>60) as the uptitration gate. Make all user-adjustable.

US labelling vs guideline for bisoprolol and nebivolol in HF

“Bisoprolol fumarate is contraindicated in patients with cardiogenic shock, overt cardiac failure, second or third degree AV block, and marked sinus bradycardia.”
Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· CONTRAINDICATIONS Source
“BYSTOLIC is indicated for the treatment of hypertension, to lower blood pressure [see Clinical Studies ( 14.1 )].”
BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· 1.1 Hypertension Source
“Bisoprolol, sustained-release metoprolol (succinate), and carvedilol have been shown to reduce the risk of death in patients with HFrEF, whereas nebivolol only reduced the combined endpoint of all-cause mortality and CV hospitalization.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations (1-3).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 43 Source
“Treatment of stable mild and moderate chronic heart failure in addition to standard therapies in elderly patients ≥ 70 years.”
Nebivolol 5 mg tablets, UK SmPC, Amarox Limited (emc); Nebilet-equivalent text incl. CHF indication (2025)· 4.1 Therapeutic indications: Chronic heart failure (CHF) Source

Tool uses esc2026: The FDA hierarchy cannot apply to HF use because neither US label has an HF indication. Use ESC 2026 Table 11 doses and the EU/UK SmPCs (Cardicor, nebivolol) for HF-specific renal and contraindication statements. Show nebivolol as ESC-listed but not mortality-proven and not included in AHA/ACC. In the ACC/AHA view, show only bisoprolol, carvedilol and metoprolol succinate.

Beta-blockers in HFrEF with atrial fibrillation

“Beta-blockers are recommended in stable patients with HFrEF and AF as first-line therapy for short- and long-term rate control.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 14 Source
“Based on our findings, β blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation.”
Kotecha D, et al. Efficacy of beta blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis. Lancet 2014;384:2235-43 (PubMed abstract, PMID 25193873) (2014)· Abstract Source
“A retrospective subgroup individual-patient data meta-analysis of all major beta-blocker trials in HFrEF showed no benefit on hospital admissions and mortality in the subgroup of patients with HFrEF with AF.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source

Tool uses esc2026: Informational, not kidney-related. ESC 2026 keeps beta-blockers first-line for rate control in HFrEF + AF while acknowledging no prognostic benefit in AF. Show both. No change to kidney matrix status.

Open questions

Dialysis agent preference: should the tool suggest carvedilol as the preferred beta-blocker in haemodialysis (RCT evidence + negligible dialytic clearance), and flag metoprolol/bisoprolol as dialyzable (Tieu 2018) despite their labels and ESC CVD-CKD calling bisoprolol low-dialysability?
G4/G5 status: ESC CVD-CKD gives IIb at eGFR 15-29 and nothing below 15, while KDIGO 2026 lists beta-blockers at <15. Is 'caution' for initiation and 'allowed' for continuation acceptable, or should G5 initiation be 'no-data'?
Nebivolol: show it in the ESC view only (Table 11, footnote e: not mortality-proven), and hide it from the ACC/AHA view? Also apply the EU SmPC 'not recommended' rule at serum creatinine ≥250 µmol/L and the HR <60 / SBP <90 contraindications?
HR defaults: ESC Table S6 (<50 caution), carvedilol label (<55 reduce), nebivolol SmPC (<60 do not start), ESC CVD-CKD Fig. 11 (>60 to uptitrate). Which global default should the tool use? Proposed: 50 caution / 60 uptitration gate, with per-drug label overrides.
AKI continuation status: set to 'caution' because of the carvedilol label (reduce/stop if renal function worsens in at-risk patients) and haemodynamic coupling. Owner may prefer 'allowed', since ESC 2026 excludes beta-blockers from its AKI discontinuation list.
Transplant: no HF-specific data. Status 'caution' for initiation rests only on the carvedilol-cyclosporine interaction (FDA). Owner may prefer to defer to the eGFR column and show the interaction as a note.
ACC 2024 ECDP states that beta-blockers should not be newly initiated in decompensated HF but can be continued. The extracted two-column text interleaves this sentence, so it could not be quoted verbatim. Consider re-extracting acc2024-hfref with layout preservation if the quote is wanted.

Evidence-based beta-blockers (bisoprolol, carvedilol, metoprolol succinate CR/XL, nebivolol)

FMT in HFrEF · Class I

Open in the matrix

Removal by dialysis

What each drug's prescribing information says about removal by (haemo)dialysis. Where the label is silent, this page says so rather than inferring from protein binding.

BisoprololNot removed (or not meaningfully removed)
- “Since limited data suggest that bisoprolol fumarate is not dialyzable, drug replacement is not necessary in patients undergoing dialysis.”
  Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· DOSAGE AND ADMINISTRATION, Patients with Renal or Hepatic Impairment Source
CarvedilolNot removed (or not meaningfully removed)
- “Consistent with its high degree of plasma protein‑binding, carvedilol does not appear to be cleared significantly by hemodialysis.”
  COREG (carvedilol) PI, Waylis (2026)· 12.4 Specific Populations, Renal Impairment Source
Metoprolol succinate (CR/XL)Not removed (or not meaningfully removed)
- “Hemodialysis is unlikely to make a useful contribution to metoprolol elimination”
  TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 10 OVERDOSAGE Source
NebivololNot removed (or not meaningfully removed)
- “Because of extensive drug binding to plasma proteins, hemodialysis is not expected to enhance nebivolol clearance.”
  BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· OVERDOSAGE Source
- “No studies have been conducted in patients on dialysis”
  BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· 12.4 Specific Populations Source

Drugs and doses

Drug	Brands	Start	Target	Kidney dosing
Bisoprolol	Zebeta (US, discontinued brand), Cardicor, Concor, Congescor	1.25 mg o.d.	10 mg o.d.	US label (hypertension only; no US HF indication): if CrCl <40 mL/min, start at 2.5 mg and titrate cautiously; label says limited data suggest it is not dialyzable, so no supplemental dose after dialysis. A 2018 crossover PK trial (Tieu) found bisoprolol IS substantially dialyzable. UK HF SmPC (Cardicor) has no PK data in HF with renal impairment, says to uptitrate with additional caution, and reports no therapeutic experience in HF with severely impaired renal function. The ESC HF start dose of 1.25 mg is already below the US renal start dose.
Carvedilol	Coreg, Coreg CR, Eucardic	3.125 mg b.i.d.	25 mg b.i.d. (50 mg b.i.d. if >85 kg)	No renal dose adjustment in the US label. Plasma levels are about 40-50% higher in moderate-severe renal impairment but with similar ranges; not significantly cleared by haemodialysis. The label warns of rare deterioration of renal function in HF, with risk in SBP <100 mmHg, ischaemic or diffuse vascular disease, or underlying renal insufficiency: monitor renal function during up-titration and reduce or stop if it worsens. The only RCT in dialysis patients with HF (Cice 2003) used carvedilol.
Metoprolol succinate (CR/XL)	Toprol-XL, Beloc-Zok	12.5–25 mg o.d.	200 mg o.d.	US label: no dose reduction needed in chronic renal failure. The label says haemodialysis is unlikely to contribute usefully to elimination, but modern high-flux HD clears metoprolol extensively (Tieu 2018: 87 mL/min). Mullens 2022 says the dose may need adjusting in dialysis.
Nebivolol	Bystolic (US), Nebilet	1.25 mg o.d.	10 mg o.d.	US label (hypertension only; no US HF indication): if CrCl <30 mL/min, start at 2.5 mg and titrate slowly; not studied in dialysis. Highly protein-bound, so HD is not expected to enhance clearance. EU/UK SmPC (HF indication, age ≥70, from SENIORS): no adjustment in mild-moderate renal insufficiency; not recommended in severe renal insufficiency (serum creatinine ≥250 µmol/L, about ≥2.8 mg/dL), with no experience in that group. EU/UK contraindications also include pre-treatment HR <60 bpm and SBP <90 mmHg.

Status by kidney stage

Stage	Initiate	Continue
G1	Recommended Class I in stable symptomatic HFrEF. Start low once the patient is stable and euvolaemic, then uptitrate to target or highest tolerated dose.	Recommended Continue lifelong at the highest tolerated dose, even if symptoms or LVEF improve.
G2	Recommended Same as without CKD: Class I in stable symptomatic HFrEF, with no renal dose adjustment.	Recommended Continue at the highest tolerated dose.
G3a	Recommended ESC CVD-CKD 2026 gives Class I at eGFR ≥30. In the IPD meta-analysis, mortality benefit in sinus rhythm was preserved at eGFR 45-59 (HR 0.73).	Recommended Continue. Beta-blockers do not cause an acute or long-term eGFR decline.
G3b	Recommended Class I at eGFR ≥30 (ESC CVD-CKD 2026). Mortality benefit in sinus rhythm at eGFR 30-44 (HR 0.71). Bisoprolol US label: start at 2.5 mg if CrCl <40, but the ESC HF start dose of 1.25 mg is lower anyway.	Recommended Continue. Discontinuation for renal impairment was similar to placebo in trials.
G4	Use with caution ESC CVD-CKD 2026: 'may be considered' (Class IIb, Level C) at eGFR 15-29. Benefit is uncertain because of too few patients in trials. Start low and titrate slowly. Nebivolol: start at 2.5 mg if CrCl <30 (US); EU SmPC says not recommended if creatinine ≥250 µmol/L.	Allowed Can be continued: beta-blockers are safe at low eGFR, and other indications (arrhythmia, rate control) often apply. No renal stopping rule.
G5	No data No data: no trial evidence below eGFR 15 (Beldhuis 2022: no data in CKD stage 5); the ESC CVD–CKD recommendation covers eGFR ≥15 (IIb at 15–29); KDIGO 2026 still lists a beta-blocker at eGFR <15. Individualize with nephrology input.	Allowed Continuation is reasonable (safe at low eGFR; rate and rhythm indications), with HR and BP monitoring.
dialysis	Use with caution Can be started in stable dialysis patients with HFrEF. The only RCT (Cice 2003, n=114, carvedilol) showed lower 2-year mortality. Prefer an agent with low dialytic clearance (carvedilol). Watch for bradycardia and intradialytic hypotension, especially after dose increases (BLOCADE feasibility).	Use with caution Continue. Check pre- and post-dialysis HR and BP. Dialytic clearance of metoprolol (and, per the 2018 PK trial, bisoprolol) may lower drug levels after HD. Nebivolol has not been studied in dialysis.
aki	Use with caution There is no kidney-function bar to starting, but defer until the patient is haemodynamically stable and euvolaemic. AKI often accompanies decompensation, where new starts are contraindicated if IV inotropes are needed or shock is present.	Use with caution AKI alone is not a reason to stop: ESC lists RAASi, MRA and SGLT2i (not beta-blockers) for temporary discontinuation in AKI. Hold or halve only for severe haemodynamic instability, cardiogenic shock, symptomatic bradycardia or hypotension. Carvedilol label: reduce or stop if renal function worsens in at-risk patients.
transplant	Use with caution No HF-specific data in kidney transplant recipients; use the eGFR-stage column. Carvedilol raises cyclosporine levels, so monitor cyclosporine closely after starting.	Allowed No transplant-specific restriction. Continue per eGFR stage and haemodynamics.

Cutoffs recorded from the sources

hr < 50 b.p.m. → caution (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Current or recent (<4 weeks) exacerbation of HF (e.g. hospital admission with worsening HF), heart block, or heart rate <50 b.p.m.” — esc2026-supp, p. 14
hr < 50 b.p.m. → dose-reduce if symptomatic; stop if severe deterioration (dose_reduce; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“If <50 b.p.m. and worsening symptoms, lower dose of beta-blocker, or, if severe deterioration, stop beta-blocker (rarely necessary).” — esc2026-supp, p. 15
hr < 55 b.p.m. → dose-reduce (dose_reduce; carvedilol)
“The dose of COREG should be reduced if patients experience bradycardia (heart rate less than 55 beats per minute).” — fda-carvedilol, 2.1 Heart Failure
hr < 55 b.p.m. → dose-reduce if <50-55 at rest or symptomatic (dose_reduce; nebivolol)
“Beta-adrenergic antagonists may induce bradycardia: if the pulse rate drops below 50-55 bpm at rest and/or the patient experiences symptoms that are suggestive of bradycardia, the dosage should be reduced.” — smpc-nebivolol, 4.4 Special warnings and precautions
hr < 60 b.p.m. → contraindicated (initiate; nebivolol)
“bradycardia (heart rate < 60 bpm prior to start therapy).” — smpc-nebivolol, 4.3 Contraindications
hr > 60 b.p.m. → uptitration permitted (with no symptomatic hypotension) (uptitrate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“HR >60 bpm • No symptomatic hypotension” — esc2026-ckd, p. 43
hr < 50 b.p.m. → perform ECG; review other HR-slowing drugs (hold; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Low HR (<50 b.p.m.): perform ECG, consider stopping other HR-slowing drugs, take adequate measures if high degree artrioventricular block.” — esc2026-ckd, p. 43
hr >= 70 b.p.m. → after beta-blocker at target/maximally tolerated dose, consider adding ivabradine (sinus rhythm, LVEF ≤35%) (uptitrate; ivabradine-add-on)
“As beta-blockers have well-proven morbidity and mortality benefits, they should be initiated and uptitrated to target doses first, before assessing the resting heart rate for consideration of adding ivabradine.” — esc2026, p. 34
sbp < 90 mmHg → caution (relieve congestion/achieve euvolaemia first; seek specialist advice) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“If persisting signs of congestion, hypotension (systolic <90 mmHg), raised jugular venous pressure, ascites, marked peripheral oedema—try” — esc2026-supp, p. 14
sbp < 90 mmHg → contraindicated (initiate; nebivolol)
“hypotension (systolic blood pressure < 90 mmHg).” — smpc-nebivolol, 4.3 Contraindications
sbp < 100 mmHg → monitor renal function during up-titration; reduce/stop if renal function worsens (continue; carvedilol)
“Patients at risk appear to be those with low blood pressure (systolic blood pressure less than 100 mm Hg), ischemic heart disease and diffuse vascular disease, and/or underlying renal insufficiency.” — fda-carvedilol, 5.8 Deterioration of Renal Function
egfr >= 30 mL/min/1.73m2 → recommended (Class I, Level A) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Treatment with a beta-blocker is recommended in patients with HFrEF and CKD with an eGFR ≥30 mL/min/1.73 m2 to reduce the risk of HF hospitalization and death.” — esc2026-ckd, p. 39
egfr < 30 mL/min/1.73m2 → caution (may be considered, Class IIb, Level C, for eGFR 15-29) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Treatment with a beta-blocker may be considered in patients with HFrEF and CKD with an eGFR 15–29 mL/min/1.73 m2” — esc2026-ckd, p. 40
egfr < 15 mL/min/1.73m2 → no trial data (caution) (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“No data currently exist for β-blocker therapy in patients with HFrEF with CKD stage 5 for either end point.” — beldhuis2022, p. 11
egfr < 40 mL/min (creatinine clearance) → initial dose 2.5 mg; cautious titration (US hypertension label) (dose_reduce; bisoprolol)
“In patients with hepatic impairment (hepatitis or cirrhosis) or renal dysfunction (creatinine clearance less than 40 mL/min), the initial daily dose should be 2.5 mg and caution should be used in dose-titration.” — fda-bisoprolol, DOSAGE AND ADMINISTRATION: Patients with Renal or Hepatic Impairment
egfr < 30 mL/min (creatinine clearance) → initial dose 2.5 mg; titrate slowly (US hypertension label) (dose_reduce; nebivolol)
“In patients with severe renal impairment (ClCr less than 30 mL/min) the recommended initial dose is 2.5 mg once daily; titrate up slowly if needed. BYSTOLIC has not been studied in patients receiving dialysis [see Clinical Pharmacology ( 12.4 ) ].” — fda-nebivolol, 2.1 Dosage: Renal Impairment
creatinine_abs >= 250 µmol/L (≈2.83 mg/dL) → not-recommended (initiate; nebivolol)
“There is no experience in patients with severe renal insufficiency (serum creatinine ≥ 250µmol/L). Therefore, the use of Nebivolol in these patients is not recommended.” — smpc-nebivolol, 4.2 Posology: Chronic heart failure, Patients with renal insufficiency
other < 14 days since temporary discontinuation → restart directly at previously tolerated dose if stable and euvolaemic (continue; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“If beta-blocker therapy has been temporarily discontinued for less than 14 days, it should, in most cases, be safe to initiate directly at the previously tolerated doses in stable patients.” — esc2026-supp, p. 15
other >= 2 weeks between dose doublings (outpatient, not closely monitored) → minimum uptitration interval (uptitrate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“In those patients where close monitoring is not possible, dose should be doubled at not less than 2-week intervals (slower uptitration may be needed in some patients).” — esc2026-supp, p. 15
other < 4 weeks since HF exacerbation → caution / seek specialist advice (initiate; bisoprolol, carvedilol, metoprolol-succinate, nebivolol)
“Current or recent (<4 weeks) exacerbation of HF (e.g. hospital admission with worsening HF), heart block, or heart rate <50 b.p.m.” — esc2026-supp, p. 14
other > 85 kg body weight → carvedilol target may be 50 mg b.i.d. (uptitrate; carvedilol)
“A maximum dose of 50 mg twice daily has been administered to patients with mild-to-moderate heart failure weighing over 85 kg (187 lbs.).” — fda-carvedilol, 2.1 Heart Failure

Trial evidence (informational)

CIBIS-II (bisoprolol) · NYHA III-IV, LVEF ≤35%, n=2647
All-cause mortality: HR 0.66 (95% CI 0.54-0.81)
“All-cause mortality was significantly lower with bisoprolol than on placebo (156 [11.8%] vs 228 [17.3%] deaths with a hazard ratio of 0.66 (95% CI 0.54-0.81, p<0.0001).” — cibis2-1999, Abstract
MERIT-HF (metoprolol CR/XL) · NYHA II-IV, LVEF ≤40%, n=3991
All-cause mortality: RR 0.66 (95% CI 0.53-0.81); 34% reduction
“The trial was terminated early for a statistically significant reduction in all-cause mortality (34%, nominal p= 0.00009).” — fda-metoprolol-succinate, 14.3 Heart Failure
COPERNICUS (carvedilol) · Severe HF, LVEF <25%, n=2289
All-cause mortality: HR 0.65 (95% CI 0.52-0.81)
“The trial was stopped after a median follow-up of 10 months because of an observed 35% reduction in mortality (from 19.7% per patient-year on placebo to 12.8% on carvedilol; hazard ratio 0.65, 95% CI: 0.52 to 0.81, P = 0.0014, adjusted) (see Figure 1).” — fda-carvedilol, 14.1 Heart Failure: Severe Heart Failure (COPERNICUS)
SENIORS (nebivolol) · Age ≥70, HF hospitalization in prior year or LVEF ≤35%, n=2128
All-cause mortality or CV hospital admission (death alone not significant): HR 0.86 (95% CI 0.74-0.99); death HR 0.88 (0.71-1.08)
“The primary outcome occurred in 332 patients (31.1%) on nebivolol compared with 375 (35.3%) on placebo [hazard ratio (HR) 0.86, 95% CI 0.74-0.99; P=0.039].” — flather2005, Abstract
BB-meta-HF IPD (Kotecha 2014) · 10 RCTs, n=18,254; sinus rhythm vs AF
All-cause mortality: Sinus rhythm HR 0.73 (0.67-0.80); AF HR 0.97 (0.83-1.14)
“β-blocker therapy led to a significant reduction in all-cause mortality in patients with sinus rhythm (hazard ratio 0·73, 0·67-0·80; p<0·001), but not in patients with atrial fibrillation (0·97, 0·83-1·14; p=0·73), with a significant p value for interaction of baseline rhythm (p=0·002).” — kotecha2014, Abstract
BB-meta-HF IPD by LVEF (Cleland 2018) · 11 RCTs, sinus rhythm, LVEF 40-49% subgroup n=575
CV death (LVEF 40-49%): HR 0.48 (95% CI 0.24-0.97); all-cause HR 0.59 (0.34-1.03)
“Cardiovascular death occurred in 13/292 [4.5%] with beta-blockers and 26/283 [9.2%] with placebo; adjusted HR 0.48 (95% CI 0.24-0.97).” — cleland2018, Abstract
BB-meta-HF IPD by eGFR (Kotecha 2019) · 10 RCTs, LVEF <50%, sinus rhythm, n=13,861
All-cause mortality: eGFR 45-59: HR 0.73 (0.62-0.86); eGFR 30-44: HR 0.71 (0.58-0.87)
“In 13,861 patients in sinus rhythm, beta-blockers reduced mortality versus placebo; adjusted hazard ratio (HR): 0.73 for eGFR 45 to 59 ml/min/1.73 m2 (95% CI: 0.62 to 0.86; p < 0.001) and 0.71 for eGFR 30 to 44 ml/min/1.73 m2 (95% CI: 0.58 to 0.87; p = 0.001).” — kotecha2019, Abstract
Cice 2003 (carvedilol in dialysis) · Dialysis + dilated cardiomyopathy, n=114
2-year all-cause mortality: 51.7% vs 73.2% (p<0.01)
“At two years, 51.7% of the patients died in the carvedilol group, compared with 73.2% in the placebo group (p < 0.01).” — cice2003, Abstract
ESC 2026 summary · HFrEF
Death: Bisoprolol, metoprolol succinate, carvedilol reduce death; nebivolol only the composite
“Bisoprolol, sustained-release metoprolol (succinate), and carvedilol have been shown to reduce the risk of death in patients with HFrEF, whereas nebivolol only reduced the combined endpoint of all-cause mortality and CV hospitalization.” — esc2026, p. 34
ESC 2026 summary (LVEF 40-50%) · HFrEF/HFmrEF in sinus rhythm
CV and all-cause mortality: Similar reductions at LVEF <40% and 40-50%
“An individual patient meta-analysis of RCTs of beta-blockers suggested similar reductions in CV and all-cause mortality for patients in sinus rhythm with HFrEF who had LVEF <40% and LVEF 40%–50%.” — esc2026, p. 34

Acute kidney injury

“Temporary discontinuation of beta-blockers and ARNIs/ACE-Is/ARBs is advised in patients with severe haemodynamic instability.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source
“Importantly, misinterpretation of changes in kidney function, leading to inappropriate discontinuation or down-regulation of doses of FMT, is a leading cause of insufficient FMT and should be avoided, both in decompensated and chronic HF.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source
“In patients experiencing mild decrease of renal function or asymptomatic reduction of blood pressure during HF hospitalization, diuresis and other GDMT should not routinely be discontinued (6-11).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 80 Source
“Usually beta-blocker do not cause drop in eGFR but a drop in blood pressure is expected which can result in a drop in eGFR.”
Beldhuis 2022 Circulation: Evidence-based medical therapy in HFrEF patients with CKD (2022)· p. 8 Source

Dialysis

“CONCLUSIONS: Carvedilol reduced morbidity and mortality in dialysis patients with dilated cardiomyopathy.”
Cice G et al. Carvedilol increases two-year survival in dialysis patients with dilated cardiomyopathy. J Am Coll Cardiol 2003 (PMID 12742278, abstract) (2003)· Abstract Source
“49 of 72 run-in participants (68%; 95% CI, 57%-79%) achieved the primary outcome. 5 of the 23 withdrawals from run-in were attributable to bradycardia or hypotension.”
Roberts MA et al. BLOCADE Feasibility Study. Am J Kidney Dis 2016 (PMID 26717861, abstract) (2016)· Abstract Source
“Overall, there were 4 IDH events per 100 hemodialysis sessions; in participants allocated to carvedilol versus placebo, respectively, there were 7 versus 2 IDH events per 100 hemodialysis sessions (P=0.1) in the 2 weeks immediately following a dose increase and 4 versus 3 IDH events per 100 hemodialysis sessions after no dose increase (P=0.7).”
Roberts MA et al. BLOCADE Feasibility Study. Am J Kidney Dis 2016 (PMID 26717861, abstract) (2016)· Abstract Source
“Among maintenance dialysis patients with hypertension and left ventricular hypertrophy, atenolol-based antihypertensive therapy may be superior to lisinopril-based therapy in preventing cardiovascular morbidity and all-cause hospitalizations.”
Agarwal R et al. Atenolol or lisinopril in hemodialysis (HDPAL). Nephrol Dial Transplant 2014 (PMID 24398888, abstract) (2014)· Abstract Source
“Using the recovery clearance method, the dialytic clearance values for atenolol, metoprolol, bisoprolol, and carvedilol were 72, 87, 44, and 0.2 ml/min, respectively (P<0.001).”
Tieu A et al. Beta-blocker dialyzability in maintenance hemodialysis: randomized PK trial. Clin J Am Soc Nephrol 2018 (PMID 29519953, abstract) (2018)· Abstract Source
“Initiation of a high- versus low-dialyzability β-blocker was associated with a higher risk of death in the following 180 days (relative risk, 1.4; 95% confidence interval, 1.1 to 1.8; P<0.01).”
Weir MA et al. Beta-blocker dialyzability and mortality in older hemodialysis patients. J Am Soc Nephrol 2015 (PMID 25359874, abstract) (2015)· Abstract Source
“Pooled data suggest highly dialyzable β-blockers are associated with similar mortality events and fewer cardiovascular events compared with poorly dialyzable β-blockers.”
Tella A, et al. Beta-blocker use and cardiovascular outcomes in hemodialysis: a systematic review. Kidney Med 2022;4:100460 (PubMed abstract, PMID 35539430) (2022)· Abstract Source
“Intradialytic hypotension was more common in those on carvedilol (a poorly dialyzable β-blocker) compared with those on metoprolol (a highly dialyzable β-blocker; adjusted incidence rate ratio, 1.10; 95% CI, 1.09-1.11).”
Tella A, et al. Beta-blocker use and cardiovascular outcomes in hemodialysis: a systematic review. Kidney Med 2022;4:100460 (PubMed abstract, PMID 35539430) (2022)· Abstract Source
“The use of dialyzable and non-dialyzable beta-blockers had no impact on the risk of all-cause mortality, overall MACE, and AMI among dialysis patients.”
Yeh TH, et al. Impact of type of dialyzable beta-blockers on subsequent risk of mortality in patients receiving dialysis: a systematic review and meta-analysis. PLoS One 2022;17:e0279680 (PubMed abstract, PMID 36584227) (2022)· Abstract Source
“The use of β-blockers was associated with a reduced risk of heart failure-related mortality in the PD population.”
Gao M, et al. Association between beta-blocker utilization and heart failure mortality in the peritoneal dialysis population: a cohort study. Clin Kidney J 2024;17:sfae022 (PubMed abstract, PMID 38444751) (2024)· Abstract Source
“Consistent with its high degree of plasma protein‑binding, carvedilol does not appear to be cleared significantly by hemodialysis.”
COREG (carvedilol) PI, Waylis (2026)· 12.4 Specific Populations: Renal Impairment Source
“Since limited data suggest that bisoprolol fumarate is not dialyzable, drug replacement is not necessary in patients undergoing dialysis.”
Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· DOSAGE AND ADMINISTRATION: Patients with Renal or Hepatic Impairment Source
“Renal clearance of nebivolol is decreased in patients with severe renal impairment. BYSTOLIC has not been studied in patients receiving dialysis [see Clinical Pharmacology ( 12.4 ) and Dosage and Administration ( 2.1 )].”
BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· Warnings and Precautions: Impaired Renal Function Source
“Unlike the RAAS inhibitor trials, many RCTs have included patients with eGFR as low as 15 mL/min/1.73 m2 and, in one small trial, patients on dialysis.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 36 Source

Kidney transplant

“In about 30% of subjects, the dose of cyclosporine had to be reduced in order to maintain cyclosporine concentrations within the therapeutic range, while in the remainder no adjustment was needed.”
COREG (carvedilol) PI, Waylis (2026)· 7.3 Cyclosporine Source
“Recommendation 4.1: We recommend that a dihydropyridine calcium channel blocker (CCB) or an ARB be used as the first-line antihypertensive agent in adult kidney transplant recipients (1C).”
KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in CKD (2021)· p. 30 (summary of recommendations; also Chapter 4, p. 60) Source

Albuminuria

No verbatim statement found for this cell.

Monitoring

“Monitor heart rate, blood pressure, and clinical status (symptoms, signs—especially signs of congestion, body weight).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source
“Titrate BB to maximal dose • Monitor BP and HR”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 43 Source
“Monitor heart rate in patients receiving TOPROL-XL. If severe bradycardia develops, reduce or stop TOPROL- XL.”
TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 5.4 Bradycardia Source
“Uptitration of FMT at least every 1–2 weeks in patients with HF, guided by symptoms, vital signs, and laboratory findings, to achieve optimal target doses shown to be efficacious in RCTs is recommended to reduce the risk of HFH or death.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 11 (summary of recommendations; same text in Recommendation Table 5, p. 37) Source

In-hospital initiation

“In patients admitted with DHF, beta-blockers should be cautiously initiated in hospital, once the patient is haemodynamically stabilized.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“In patients hospitalized with DHF/WHF—after stabilizing, relieving congestion, and, if possible, restoring 'euvolaemia' (but ideally before discharge).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 14 Source
“In patients with HFrEF requiring hospitalization, preexisting GDMT should be continued and optimized to improve outcomes, unless contraindicated (1-5).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 80 Source
“Patients with cardiogenic shock or who have decompensated heart failure requiring the use of intravenous inotropic therapy. Such patients should first be weaned from intravenous therapy before initiating COREG.”
COREG (carvedilol) PI, Waylis (2026)· 4 Contraindications Source

Outpatient

“Beta-blockers should be initiated early in clinically stable patients, at low doses and gradually uptitrated to the highest tolerated dose.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“The recommended starting dose of COREG is 3.125 mg twice daily for 2 weeks. If tolerated, patients may have their dose increased to 6.25, 12.5, and 25 mg twice daily over successive intervals of at least 2 weeks.”
COREG (carvedilol) PI, Waylis (2026)· 2.1 Heart Failure Source
“If increasing congestion, increase dose of diuretic or halve a dose of beta-blocker (if increasing diuretic dose does not work).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source
“Beta-blockers should not be stopped suddenly unless absolutely necessary (there is a risk of a 'rebound' increase in myocardial ischaemia or infarction and arrhythmias).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source

Where sources disagree

Dialyzability of metoprolol and bisoprolol (agent choice in haemodialysis)

“Hemodialysis is unlikely to make a useful contribution to metoprolol elimination [see Clinical Pharmacology (12.3)].”
TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 10 Overdosage Source
“Since limited data suggest that bisoprolol fumarate is not dialyzable, drug replacement is not necessary in patients undergoing dialysis.”
Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· DOSAGE AND ADMINISTRATION: Patients with Renal or Hepatic Impairment Source
“Depending on drug kinetics, dose adjustment may be required for some beta-blockers (e.g. atenolol, nadolol) but not others (e.g. bisoprolol, metoprolol, carvedilol), and low-dialysability beta-blockers (i.e. bisoprolol or propranolol) may be preferred to avoid under-treatment.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 48 Source
“Atenolol and metoprolol are extensively cleared by hemodialysis compared with the negligible dialytic clearance of carvedilol. Contrary to estimates of dialyzability on the basis of previous literature, our data indicate that bisoprolol is also dialyzable.”
Tieu A et al. Beta-blocker dialyzability in maintenance hemodialysis: randomized PK trial. Clin J Am Soc Nephrol 2018 (PMID 29519953, abstract) (2018)· Abstract Source
“Nevertheless, it is important to remember that carvedilol is not dialyzable (and bisoprolol and nebivolol to a limited extent) while more water soluble beta-blockers (being metoprolol and atenolol) are removed by dialysis, so dose of metoprolol might need to be adjusted (atenolol is not advised in HF).”
Mullens 2022 EJHF: Renal effects of GDMT in HF, HFA/ESC consensus statement (2022)· p. 8 Source
“Initiation of a high- versus low-dialyzability β-blocker was associated with a higher risk of death in the following 180 days (relative risk, 1.4; 95% confidence interval, 1.1 to 1.8; P<0.01).”
Weir MA et al. Beta-blocker dialyzability and mortality in older hemodialysis patients. J Am Soc Nephrol 2015 (PMID 25359874, abstract) (2015)· Abstract Source
“Pooled data suggest highly dialyzable β-blockers are associated with similar mortality events and fewer cardiovascular events compared with poorly dialyzable β-blockers.”
Tella A, et al. Beta-blocker use and cardiovascular outcomes in hemodialysis: a systematic review. Kidney Med 2022;4:100460 (PubMed abstract, PMID 35539430) (2022)· Abstract Source

Beta-blockers at eGFR 15-29 and <15 (G4/G5)

“Treatment with a beta-blocker may be considered in patients with HFrEF and CKD with an eGFR 15–29 mL/min/1.73 m2”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 40 Source
“<15 15–29 30–59 ≥60 • ß-blocker • Hydralazine/ nitrates”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 11
“In contrast, in CKD stage 4, there was also no clear benefit of β-blocker therapy (Figure S5A), but also no evidence of harm.”
Beldhuis 2022 Circulation: Evidence-based medical therapy in HFrEF patients with CKD (2022)· p. 11 Source
“Due to exclusion criteria, there were insufficient patients with severe renal dysfunction (eGFR <30 ml/min/1.73 m2) to draw conclusions.”
Kotecha D, et al. Impact of renal impairment on beta-blocker efficacy in patients with heart failure. J Am Coll Cardiol 2019;74:2893-904 (PubMed abstract, PMID 31806133) (2019)· Abstract Source
“Even in most patients with CKD the initiation of beta-blockers, ACE-Is/ARNIs/ARBs, SGLT2-Is, and MRAs is recommended.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66 Source

Decompensated HF: labelled contraindication vs guideline continuation/in-hospital initiation

“TOPROL-XL is contraindicated in severe bradycardia, second- or third-degree heart block, cardiogenic shock, decompensated heart failure, sick sinus syndrome (unless a permanent pacemaker is in place), and in patients who are hypersensitive to any component of this product.”
TOPROL-XL (metoprolol succinate) PI, Melinta (2026)· 4 Contraindications Source
“Patients with cardiogenic shock or who have decompensated heart failure requiring the use of intravenous inotropic therapy. Such patients should first be weaned from intravenous therapy before initiating COREG.”
COREG (carvedilol) PI, Waylis (2026)· 4 Contraindications Source
“In patients admitted with DHF, beta-blockers should be cautiously initiated in hospital, once the patient is haemodynamically stabilized.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“Temporary discontinuation of beta-blockers and ARNIs/ACE-Is/ARBs is advised in patients with severe haemodynamic instability.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source
“In patients with HFrEF requiring hospitalization, preexisting GDMT should be continued and optimized to improve outcomes, unless contraindicated (1-5).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 80 Source

Heart-rate cutoff for caution / dose reduction

“If <50 b.p.m. and worsening symptoms, lower dose of beta-blocker, or, if severe deterioration, stop beta-blocker (rarely necessary).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 15 Source
“If pulse rate drops below 55 beats per minute, the dosage should be reduced.”
COREG (carvedilol) PI, Waylis (2026)· 5.2 Bradycardia Source
“bradycardia (heart rate < 60 bpm prior to start therapy).”
Nebivolol 5 mg tablets, UK SmPC, Amarox Limited (emc); Nebilet-equivalent text incl. CHF indication (2025)· 4.3 Contraindications Source
“HR >60 bpm • No symptomatic hypotension”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 43 Source

US labelling vs guideline for bisoprolol and nebivolol in HF

“Bisoprolol fumarate is contraindicated in patients with cardiogenic shock, overt cardiac failure, second or third degree AV block, and marked sinus bradycardia.”
Bisoprolol fumarate tablets PI, Unichem (no Zebeta SPL on DailyMed) (2022)· CONTRAINDICATIONS Source
“BYSTOLIC is indicated for the treatment of hypertension, to lower blood pressure [see Clinical Studies ( 14.1 )].”
BYSTOLIC (nebivolol) tablets, prescribing information, Allergan Inc. (2025)· 1.1 Hypertension Source
“Bisoprolol, sustained-release metoprolol (succinate), and carvedilol have been shown to reduce the risk of death in patients with HFrEF, whereas nebivolol only reduced the combined endpoint of all-cause mortality and CV hospitalization.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source
“In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations (1-3).”
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (2022)· p. 43 Source
“Treatment of stable mild and moderate chronic heart failure in addition to standard therapies in elderly patients ≥ 70 years.”
Nebivolol 5 mg tablets, UK SmPC, Amarox Limited (emc); Nebilet-equivalent text incl. CHF indication (2025)· 4.1 Therapeutic indications: Chronic heart failure (CHF) Source

Beta-blockers in HFrEF with atrial fibrillation

“Beta-blockers are recommended in stable patients with HFrEF and AF as first-line therapy for short- and long-term rate control.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 14 Source
“Based on our findings, β blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation.”
Kotecha D, et al. Efficacy of beta blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis. Lancet 2014;384:2235-43 (PubMed abstract, PMID 25193873) (2014)· Abstract Source
“A retrospective subgroup individual-patient data meta-analysis of all major beta-blocker trials in HFrEF showed no benefit on hospital admissions and mortality in the subgroup of patients with HFrEF with AF.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 34 Source

Open questions

Dialysis agent preference: should the tool suggest carvedilol as the preferred beta-blocker in haemodialysis (RCT evidence + negligible dialytic clearance), and flag metoprolol/bisoprolol as dialyzable (Tieu 2018) despite their labels and ESC CVD-CKD calling bisoprolol low-dialysability?
G4/G5 status: ESC CVD-CKD gives IIb at eGFR 15-29 and nothing below 15, while KDIGO 2026 lists beta-blockers at <15. Is 'caution' for initiation and 'allowed' for continuation acceptable, or should G5 initiation be 'no-data'?
Nebivolol: show it in the ESC view only (Table 11, footnote e: not mortality-proven), and hide it from the ACC/AHA view? Also apply the EU SmPC 'not recommended' rule at serum creatinine ≥250 µmol/L and the HR <60 / SBP <90 contraindications?
HR defaults: ESC Table S6 (<50 caution), carvedilol label (<55 reduce), nebivolol SmPC (<60 do not start), ESC CVD-CKD Fig. 11 (>60 to uptitrate). Which global default should the tool use? Proposed: 50 caution / 60 uptitration gate, with per-drug label overrides.
AKI continuation status: set to 'caution' because of the carvedilol label (reduce/stop if renal function worsens in at-risk patients) and haemodynamic coupling. Owner may prefer 'allowed', since ESC 2026 excludes beta-blockers from its AKI discontinuation list.
Transplant: no HF-specific data. Status 'caution' for initiation rests only on the carvedilol-cyclosporine interaction (FDA). Owner may prefer to defer to the eGFR column and show the interaction as a note.
ACC 2024 ECDP states that beta-blockers should not be newly initiated in decompensated HF but can be continued. The extracted two-column text interleaves this sentence, so it could not be quoted verbatim. Consider re-extracting acc2024-hfref with layout preservation if the quote is wanted.