Selective beta-1 blocker Pregnancy: Bisoprolol should not be used during pregnancy unless clearly necessary. Beta-adrenoceptor blockers reduce placental perfusion, which has been associated with growth retardation, intrauterine death, abortion or early labour, and adverse effects such as hypoglycaemia and bradycardia may occur in the fetus and newborn infant (generally expected within the first 3 days). If treatment is considered necessary, uteroplacental blood flow and fetal growth should be monitored and the newborn closely monitored; if harmful effects occur, alternative treatment should be considered. Breast-feeding: it is not known whether bisoprolol is excreted in human milk, therefore breast-feeding is not recommended during administration.

Bisoprolol (Heart Failure in Elderly)

Brand names: Cardicor, Emcor

Bisoprolol is a cardioselective beta-blocker; this page concerns its use as a prognostic, dose-titrated therapy for chronic heart failure with reduced ejection fraction in older patients.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Titration phase for stable chronic heart failure: 1.25 mg once daily for 1 week; if well tolerated increase to 2.5 mg once daily for a further week, then 3.75 mg once daily for a further week, then 5 mg once daily for the 4 following weeks, then 7.5 mg once daily for the 4 following weeks, then 10 mg once daily for maintenance therapy

Route: Oral - taken in the morning, may be taken with food; tablets should not be chewed. The orodispersible tablet is placed on the tongue and allowed to disintegrate before swallowing, with or without water.

Frequency: Once daily

Max: 10 mg once daily (the maximum recommended dose)

OLDER PEOPLE: no dosage adjustment is required (section 4.2). Patients should be stable (without acute failure) when bisoprolol treatment is initiated, and it is recommended that the treating physician be experienced in the management of chronic heart failure. Standard treatment of chronic heart failure consists of an ACE inhibitor (or an angiotensin receptor blocker in case of ACE inhibitor intolerance), a beta-blocker, diuretics, and when appropriate cardiac glycosides. Transient worsening of heart failure, hypotension or bradycardia may occur during the titration period and thereafter; close monitoring of vital signs (heart rate, blood pressure) and of symptoms of worsening heart failure is recommended during titration, and symptoms may already occur within the first day after initiating therapy. TREATMENT MODIFICATION: if the maximum recommended dose is not well tolerated, gradual dose reduction may be considered. In case of transient worsening of heart failure, hypotension or bradycardia, reconsideration of the dosage of the concomitant medication is recommended; it may also be necessary to temporarily lower the bisoprolol dose or to consider discontinuation, with reintroduction and/or uptitration considered once the patient becomes stable again. Treatment is generally long term. DISCONTINUATION: gradual dose decrease is recommended, since abrupt withdrawal may lead to acute deterioration of the patient's condition; if beta-blocker therapy must be withdrawn before surgery this should be done gradually and completed about 48 hours before anaesthesia. INDICATION SCOPE: the fetched SPC covers the chronic heart failure indication only and contains no hypertension or angina posology - any such regimen must be sourced from an SPC licensed for that indication. PAEDIATRIC (not per kg, so not carried in paedDose): there is no paediatric experience with bisoprolol, therefore its use cannot be recommended in paediatric patients - no paediatric dose is stated.

Dose adjustments

Renal

There is no information regarding the pharmacokinetics of bisoprolol in patients with chronic heart failure and impaired hepatic or renal function; uptitration of the dose in these populations should therefore be made with additional caution (section 4.2). There is no therapeutic experience of bisoprolol treatment of heart failure in patients with severely impaired renal function or severely impaired hepatic function (section 4.4). No numeric renal dose adjustment is stated in the source.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Acute heart failure or episodes of heart failure decompensation requiring intravenous inotropic therapy
Cardiogenic shock
Second or third degree AV block; sick sinus syndrome; sinoatrial block; symptomatic bradycardia
Symptomatic hypotension
Severe bronchial asthma
Severe forms of peripheral arterial occlusive disease or severe forms of Raynaud's syndrome
Untreated phaeochromocytoma
Metabolic acidosis
Hypersensitivity to bisoprolol or to any of the excipients

Side effects

Bradycardia (very common); worsening of heart failure (common); AV conduction disturbances (uncommon)
Dizziness and headache (common); syncope (rare)
Feeling of coldness or numbness in the extremities and hypotension (common); orthostatic hypotension (uncommon)
Gastrointestinal complaints such as nausea, vomiting, diarrhoea and constipation (common)
Asthenia and fatigue (common); bronchospasm in patients with bronchial asthma or a history of obstructive airways disease (uncommon)

Interactions

Calcium antagonists of the verapamil or diltiazem type - combination generally not recommended (section 4.4)
Class I antiarrhythmic drugs - combination generally not recommended (section 4.4)
Centrally acting antihypertensive drugs - combination generally not recommended (section 4.4)
Ongoing desensitisation therapy and allergens - bisoprolol may increase both the sensitivity towards allergens and the severity of anaphylactic reactions, and epinephrine (adrenaline) treatment does not always yield the expected therapeutic effect (section 4.4)
Diabetes mellitus with large fluctuations in blood glucose - symptoms of hypoglycaemia can be masked (section 4.4)
General anaesthesia - the anaesthetist must be aware of beta-blockade because of the potential for interactions with other drugs resulting in bradyarrhythmias, attenuation of reflex tachycardia and decreased reflex ability to compensate for blood loss; maintenance beta-blockade is currently recommended to be continued peri-operatively (section 4.4)
NOTE: SPC section 4.5 was not captured in this bundle; the entries above are those stated within section 4.4 - the full interaction section must be checked against the SPC

Clinical monograph

How it works

By selectively blocking cardiac beta-1 adrenoceptors it counters chronic sympathetic overactivity in heart failure, reducing heart rate and myocardial workload and improving long-term cardiac function and survival.

Prescribing in practice

Start only when the patient is clinically stable, begin at a low dose and up-titrate slowly, as abrupt initiation or rapid escalation can transiently worsen heart failure; never stop abruptly.
In older patients monitor closely for bradycardia, hypotension, fatigue and fluid retention during titration, and avoid in significant conduction block, decompensated failure or severe asthma.
Use caution when combined with other rate-limiting drugs and watch for blunting of hypoglycaemia warning signs in diabetes.

Monitoring

Monitor heart rate, blood pressure, symptoms and signs of fluid status and weight at each up-titration step and during dose changes.

Counselling the patient

Never stop the medicine suddenly; any changes should be made by your clinician.
Some tiredness early on usually settles as the dose is increased.
Report increasing breathlessness, swelling, weight gain, or a very slow pulse or dizziness.

Evidence & guidelines

Mortality benefit of bisoprolol in heart failure was established by the CIBIS-II trial and is reflected in NICE and ESC heart-failure guidance.

Reference: NICE NG106 Heart Failure; ESC HF Guidelines 2021; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways