Nebivolol vs Bisoprolol: What to Choose and for Whom

When a doctor decides that a patient needs a beta-blocker, the choice often narrows to a few modern molecules — and nebivolol and bisoprolol are among the most popular. The editorial team examines in which clinical situations each of them has advantages, what physically active people should know and why replacing one drug with another on your own is a bad idea.

When a beta-blocker is truly needed

Beta-blockers have clear indications for which their benefit is best proven: heart failure with reduced ejection fraction, a previous myocardial infarction, angina, control of heart rate in atrial fibrillation. In these situations a beta-blocker is not “one of the options” but an important part of therapy.

In hypertension, the role of beta-blockers has been debated for years. The ESC/ESH 2018 guidelines recommended them primarily in specific situations — in concomitant ischemic disease, heart failure, arrhythmias, in women planning pregnancy. The ESH 2023 guidelines consider them among the main classes but emphasize the importance of comorbid conditions for the choice.

So the first question is not “nebivolol or bisoprolol” but “is a beta-blocker needed at all.” For a young person with uncomplicated hypertension, a doctor will more often start with a different class of drugs.

One should also rule out secondary causes of tachycardia and elevated blood pressure: hyperthyroidism, anemia, excessive consumption of caffeine and stimulants, taking of hormonal drugs. A beta-blocker can “mask” the symptoms without eliminating the cause.

Heart failure and ischemic disease

In heart failure with reduced ejection fraction, bisoprolol has the strongest data on reducing mortality — the CIBIS-II study. Therefore, in many clinics it is precisely the “default drug” for such patients of younger and middle age.

Nebivolol has an evidence base in elderly patients (from 70 years) based on the results of SENIORS. For an elderly patient with heart failure it may be a fully justified choice, especially if a vasodilating effect is also needed.

Regardless of the chosen molecule, in heart failure the dose is increased gradually, from the minimum starting dose, under the control of pulse, blood pressure and well-being. This titration is performed exclusively by a doctor, since temporary worsening of the condition is possible at the start of treatment.

In stable coronary heart disease, both drugs effectively reduce the frequency of angina attacks by slowing the pulse. The choice here depends on tolerability, kidney and liver function and concomitant drugs.

Hypertension and metabolic profile

If a beta-blocker is needed to control blood pressure, arguments in favor of nebivolol may be signs of endothelial dysfunction, metabolic syndrome or complaints of erectile function against the background of other beta-blockers. NO-mediated vasodilation theoretically softens some of the undesirable effects of the class, although convincing comparative data are scarce.

Bisoprolol may be more appropriate in people taking CYP2D6 inhibitors (some antidepressants), since its concentration hardly depends on these enzymes. A balanced renal and hepatic elimination also makes it predictable in people with moderate impairment of the function of one of the organs.

These arguments are not absolute: in each specific case the doctor weighs them together with other factors — price, availability, the patient’s experience with previous therapy.

Physically active people and athletes

For people who train regularly, a beta-blocker is a drug with a noticeable effect on well-being. A lower maximum pulse, faster fatigue during aerobic work, sometimes cold hands and feet. For strength training the effect is usually less noticeable than for running, rowing or cycling.

During therapy, heart-rate zones calculated by age or by a test without the drug lose their meaning. Intensity is better assessed by a scale of subjective exertion or checked by a stress test conducted while already on treatment.

Beta-blockers lower the pulse but do not eliminate the causes of tachycardia or hypertension. If the symptoms appeared against the background of stimulants, “fat burners” or hormonal drugs, a beta-blocker is not a way to make taking them safer — the cause must be eliminated and an examination by a cardiologist undertaken.

It is important for professional athletes to remember: beta-blockers are on the WADA Prohibited List in certain sports where precision and control of tremor are important (in particular shooting and archery). If the drug is needed for medical indications, a therapeutic use exemption may be required.

Safe change and discontinuation of the drug

Beta-blockers must not be discontinued abruptly. After prolonged use the sensitivity of the receptors changes, and sudden cessation can cause tachycardia, a rise in blood pressure, worsening of angina, and in patients with ischemic disease — a heart attack.

Switching from nebivolol to bisoprolol or vice versa is done by a doctor, calculating the equivalent dose and monitoring pulse and blood pressure. The milligrams of different beta-blockers are not interchangeable.

• Do not change the dose on your own, even if the blood pressure is “normal.”
• Inform the doctor about all medications and supplements, in particular antidepressants and antiarrhythmic drugs.
• If the resting pulse is below 50 or with dizziness, see a doctor.
• Warn the doctor about asthma, diabetes, problems with peripheral circulation.

In diabetes mellitus, beta-blockers can mask the symptoms of hypoglycemia, in particular palpitations. This applies to both drugs and requires careful monitoring of glucose.

Editorial conclusions

Bisoprolol is often chosen for heart failure in middle-aged patients thanks to a strong evidence base and predictable pharmacokinetics.

Nebivolol has advantages in elderly patients with heart failure and may be appropriate when vasodilation is important or when there are complaints of side effects of other beta-blockers.

For physically active people, both drugs change the pulse response to exercise, so training needs to be adapted rather than abandoning treatment on your own.

For more on the pharmacological differences — in the article “Nebivolol or Bisoprolol: What Is the Difference.” We also recommend the materials “Telmisartan vs Losartan: What to Choose and for Whom” and a review of the risks of stimulants for the heart.

References

1. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726.
2. CIBIS-II Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353(9146):9–13.
3. Flather MD, Shibata MC, Coats AJ, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J. 2005;26(3):215–225.
4. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–3104.
5. Mancia G, Kreutz R, Brunström M, et al. 2023 ESH Guidelines for the management of arterial hypertension. J Hypertens. 2023;41(12):1874–2071.
6. Münzel T, Gori T. Nebivolol: the somewhat-different beta-adrenergic receptor blocker. J Am Coll Cardiol. 2009;54(16):1491–1499.
7. World Anti-Doping Agency. The Prohibited List. Montreal: WADA; щорічне видання.