====== Bisoprolol ======

Bisoprolol is a 2nd-generation, highly β1-selective beta-blocker.

It reduces heart rate, contractility, and renin release with minimal β2 activity at therapeutic doses.

Classification:
• 2nd Generation (Cardioselective)
• No intrinsic sympathomimetic activity (ISA)

→ [[cardio:beta_blockers:start|Beta-Blockers Overview]]

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===== Mechanism of Action =====

Selective β1 blockade:

• ↓ Heart rate  
• ↓ Contractility  
• ↓ AV nodal conduction  
• ↓ Renin release  

Net Effects:

• ↓ Cardiac output  
• ↓ Blood pressure  
• ↓ Myocardial oxygen demand  

High β1 selectivity makes it safer in patients with reactive airway disease compared to nonselective agents.

Selectivity is dose-dependent.

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===== Indications =====

==== Heart Failure (HFrEF) ★ ====

• Proven mortality benefit  
• Reduces hospitalizations  
• Part of guideline-directed medical therapy (GDMT)

→ [[cardio:heart_failure:start|Heart Failure Module]]

Evidence-based HFrEF beta-blockers:

• [[cardio:beta_blockers:carvedilol|Carvedilol]]
• [[cardio:beta_blockers:metoprolol|Metoprolol Succinate]]
• ★ [[cardio:beta_blockers:bisoprolol|Bisoprolol]]

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==== Hypertension ====

• Effective antihypertensive  
• Not first-line for uncomplicated HTN  

→ [[cardio:hypertension:start|Hypertension Module]]

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==== Coronary Artery Disease ====

• Reduces myocardial oxygen demand  
• Used post-MI  

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==== Arrhythmias ====

• Rate control in atrial fibrillation  
• Suppress supraventricular tachycardia  

→ [[cardio:arrhythmias:start|Dysrhythmias Module]]

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===== Dosing in HFrEF =====

• Start low  
• Titrate slowly every 2–4 weeks  
• Initiate only when patient is euvolemic  
• Avoid starting during acute decompensation  

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===== Adverse Effects =====

• Bradycardia  
• Hypotension  
• Fatigue  
• Dizziness  
• Masked hypoglycemia  

Lower bronchospasm risk than nonselective agents.

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===== Contraindications =====

• Severe bradycardia  
• High-grade AV block (without pacemaker)  
• Cardiogenic shock  
• Acute decompensated heart failure  

Use caution in:
• Asthma (though safer than nonselective agents)
• Severe hypotension  

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===== Bisoprolol vs Other HF Beta-Blockers =====

[[cardio:beta_blockers:carvedilol|Carvedilol]]:
• α1 + β blockade  
• More vasodilation  
• More orthostatic hypotension  

[[cardio:beta_blockers:metoprolol|Metoprolol Succinate]]:
• β1 selective  
• Extended-release  

Bisoprolol:
• Highly β1 selective  
• Once-daily dosing  
• Strong mortality data  

All three reduce mortality in HFrEF.

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===== Clinical Pearls =====

✔ One of three mortality-reducing beta-blockers in HFrEF  

✔ Highly β1 selective  

✔ Once-daily dosing  

✔ Safer in mild reactive airway disease  

✔ Not first-line for uncomplicated hypertension  

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Related:

→ [[cardio:beta_blockers:start|Beta-Blockers Overview]]
→ [[cardio:heart_failure:start|Heart Failure Module]]
→ [[cardio:hypertension:start|Hypertension Module]]
→ [[cardio:arrhythmias:start|Dysrhythmias Module]]
→ [[cardio:intro:start|Return to Cardiovascular Modules]]