Ziac (Lederle), a combination of the beta-blocker bisoprolol fumarate and a very low dose (6.25 mg) of the diuretic hydrochlorothiazide, has been approved for treatment of hypertension by the US Food and Drug Administration (FDA). Bisoprolol, a new cardioselective beta-blocker with no intrinsic sympathomimetic activity, has also been marketed as a single drug (Zebeta - Lederle). The manufacturer is promoting the combination for initial treatment of hypertension with the claim that the low doses of the two drugs used together are effective in lowering blood pressure, but are each too low ...

Standard treatment for patients with heart failure has included a diuretic, digitalis and an ACE inhibitor. In recent years carvedilol, a nonselective beta-blocker with alpha-1 blocking activity, and the beta-selective blockers bisoprolol and metroprolol have also been used for this indication.

Three retrospective studies have recently reported an association between beta-blocker use and a reduction in breast cancer metastasis and recurrence. No prospective, randomized trials have been published.

Nebivolol (Bystolic - Forest) is a new beta-blocker that has been approved by the FDA for treatment of hypertension. It has been marketed in Europe since 1999 for treatment of hypertension and heart failure.

View the Comparison Table: Some Drugs for HFrEF

Some classes of drugs include so many agents that hospital formulary committees, managed care organizations and individual practitioners may find it difficult to choose among them. Fifteen beta-adrenergic receptor antagonists (beta-blockers) are now marketed for systemic use in the USA. One or more have been approved by the FDA for use in hypertension and eight other indications.

Among patients with chronic heart failure, those with a left ventricular ejection fraction (LVEF) ≤40% are considered to have heart failure with reduced ejection fraction (HFrEF). Patients with a LVEF ≥50% are considered to have heart failure with preserved ejection fraction (HFpEF). Those with a LVEF of 41-49% are an intermediate group more similar to patients with HFpEF.

The FDA has approved vericiguat (Verquvo – Merck), an oral soluble guanylate cyclase (sGC) stimulator, to reduce the risk of hospitalization for heart failure and cardiovascular (CV) death following a worsening heart failure event (hospitalization for heart failure or treatment with IV diuretics as an outpatient) in patients with symptomatic chronic heart failure and left ventricular ejection fraction (LVEF) <45%. Vericiguat is the second sGC stimulator to be marketed in the US. Riociguat (Adempas), which is FDA-approved for treatment of pulmonary arterial hypertension...

Carvedilol (Coreg - SmithKline Beecham and Boehringer-Mannheim), a betaadrenergic and alpha-adrenergic blocker approved by the FDA for treatment of hypertension in 1995, but not marketed at that time, has now been approved and marketed for treatment of mild or moderate (NYHA class II or III) heart failure stabilized on other drugs. It is being promoted as an add-on drug that reduces the morbidity and mortality of the disease.

The FDA has approved eptinezumab-jjmr (Vyepti – Lundbeck), a calcitonin gene-related peptide (CGRP) antagonist administered IV once every 3 months, for migraine prevention in adults. It is the fourth monoclonal antibody to be approved for this indication; erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality), which are all given subcutaneously once monthly (fremanezumab can also be given once every 3 months), were approved earlier.