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.

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.

Breaking drug tablets in half is a common practice. Since our last article on this subject, some new data have become available.

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.

Betaxolol (Kerlone - Searle), an oral beta-adrenergic blocker, was recently approved by the US Food and Drug Administration for once-daily treatment of hypertension. The new drug is beta 1 (cardio)-selective with no intrinsic sympathomimetic (partial agonist) activity. It is also available in a topical formulation for treatment of glaucoma (Betoptic - Medical Letter, 28:45, 1986). Beta-blockers currently available in the USA for treatment of hypertension are listed in the table below.

View the Comparison Table: Some Drugs for HFrEF

Citalopram hydrobromide (Celexa - Forest/Parke-Davis), a selective serotonin reuptake inhibitor (SSRI) available in Europe since 1989, has now been approved by the US Food and Drug Administration (FDA) for treatment of depression. It is being advertised as having a 'favorable side-effect profile.'

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.

Carteolol (Cartrol - Abbott) and penbutolol (Levatol - Reed & Carnrick), two oral beta-adrenergic blocking drugs, were recently approved by the US Food and Drug Administration for once-daily treatment of systemic hypertension. Both drugs are non-selective beta-blockers with mild partial agonist activity. Beta-blockers currently available in the USA for treatment of hypertension are listed in the table on the next page.

Doxazosin (mesylate - Roerig), an alpha1-adrenergic receptor blocker similar to prazosin (Minipress, and others) and terazosin (Hytrin), was recently approved by the US Food and Drug Administration for treatment of hypertension.