Bisoprolol (Concor)

Bisoprolol is a beta-1 selective beta blocker. It occupies the beta-1 receptors at the heart and damps the effect of adrenaline and noradrenaline there. Result: slower pulse, weaker contraction, lower oxygen demand of the heart muscle and with it lower blood pressure.

In cardiology it is one of the most thoroughly investigated agents that exists. For anyone training it is the more noticeable brake compared with nebivolol, because it lacks the NO effect that compensates part of the frequency brake there.

This information is for research and educational purposes only. No medical advice.

Beta-1 selective means bisoprolol occupies the receptors at the heart considerably more than the beta-2 receptors in bronchi, vessels and skeletal muscle. That is why it is better tolerated than the old non-selective agents. The selectivity is dose-dependent, however, and decreases as the dose rises.

The effect in heart failure runs through a different route than the blood pressure reduction. A permanently overstimulated heart wears itself out, and blocking the sympathetic drive interrupts that cycle. That is why dosing in heart failure is raised very slowly over weeks: the heart first has to adapt to the reduced stimulation, otherwise the situation worsens short-term.

CIBIS-II (Lancet 1999) is the trial everything builds on. Over 2,600 patients with heart failure, randomised to bisoprolol or placebo. The trial was stopped early because the advantage was so clear: 34 percent lower all-cause mortality. Stopping for superiority is rare and a strong signal.

CIBIS (Circulation 1994) was the predecessor. It showed the direction but was too small to prove a mortality effect. CIBIS-III (Circulation 2005) answered a practical question: is it better to start with the beta blocker or with the ACE inhibitor? Result: starting with bisoprolol was not inferior to starting with enalapril, so the order is not decisive.

TIBBS (JACC 1995) compared against nifedipine in stable angina and found considerably fewer ischaemic episodes under bisoprolol.

• Capped maximum heart rate: the mechanism, not a side effect. Cardio performance drops measurably.
• Fatigue and low drive: the most common subjective report, mostly in the first weeks.
• Bradycardia: resting heart rate below 50 means the dose comes down.
• Cold hands and feet: typical for the class.
• Masked hypoglycaemia: the warning signs are damped. Relevant for diabetics.
• Rebound on stopping: blood pressure spikes and palpitations are documented. Always taper.

Store dry, at room temperature and protected from light. Keep out of reach of children.