Rousseau MF, Chapelle F, Van Eyll C et al. Beneficial effects of metoprolol in heart failure associated with coronary artery disease: a randomized trial. The evidence is in, now the work begins. 2018;71:e13-115.Individuals with SBP and DBP in 2 different categories (e.g., elevated SBP and normal DBP) should be designated as being in the higher BP category (i.e., elevated BP).The goal of hypertension management and prevention is to achieve and maintain optimal control of BP.The 2017 ACC/AHA hypertension guideline generally recommends a target BP goal (i.e., BP to achieve with drug therapy and/or nonpharmacologic intervention) <130/80 mm Hg in all adults regardless of comorbidities or level of atherosclerotic cardiovascular disease (ASCVD) risk.Other hypertension guidelines generally have based target BP goals on age and comorbidities.Some clinicians continue to support previous target BPs recommended by JNC 8 due to concerns about the lack of generalizability of data from some clinical trials (e.g., SPRINT study) used to support the 2017 ACC/AHA hypertension guideline and potential harms (e.g., adverse drug effects, costs of therapy) versus benefits of BP lowering in patients at lower risk of cardiovascular disease.Consider potential benefits of hypertension management and drug cost, adverse effects, and risks associated with the use of multiple antihypertensive drugs when deciding a patient's BP treatment goal.For decisions regarding when to initiate drug therapy (BP threshold), the 2017 ACC/AHA hypertension guideline incorporates underlying cardiovascular risk factors.ACC/AHA currently recommend initiation of antihypertensive drug therapy in addition to lifestyle/behavioral modifications at an SBP ≥140 mm Hg or DBP ≥90 mm Hg in adults who have no history of cardiovascular disease (i.e., Adults with hypertension and diabetes mellitus, chronic kidney disease (CKD), or age ≥65 years are assumed to be at high risk for cardiovascular disease; ACC/AHA state that such patients should have antihypertensive drug therapy initiated at a BP ≥130/80 mm Hg.In stage 1 hypertension, experts state that it is reasonable to initiate drug therapy using the stepped-care approach in which one drug is initiated and titrated and other drugs are added sequentially to achieve the target BP.Black hypertensive patients generally tend to respond better to monotherapy with calcium-channel blockers or thiazide diuretics than to β-blockers.Management of mild to moderately severe (NYHA class II or III) heart failureThe American College of Cardiology Foundation (ACCF), AHA, and the Heart Failure Society of America (HFSA) recommend therapy with an ACE inhibitor, angiotensin II receptor antagonist, or angiotensin receptor-neprilysin inhibitor (ARNI) in conjunction with a β-blocker, and an aldosterone antagonist in selected patients, to reduce morbidity and mortality in patients with symptomatic heart failure and reduced left ventricular ejection fraction (LVEF) (ACCF/AHA stage C heart failure).Initiate a clinical-trial proven β-blocker (bisoprolol, carvedilol, extended-release metoprolol succinate) to reduce the risk of death in patients with chronic heart failure; benefits shown with these β-blockers not considered indicative of a β-blocker class effect.Experts recommend that β-blockers also be used in conjunction with ACE inhibitors in all patients who have asymptomatic heart failureIndividualize dosage according to patient response and tolerance.If long-term therapy is discontinued, reduce dosage gradually over a period of about 1–2 weeks.Monitor BP regularly (i.e., monthly) during therapy and adjust dosage of the antihypertensive drug until BP controlled.If unacceptable adverse effects occur, discontinue drug and initiate another antihypertensive agent from a different pharmacologic class.If adequate BP response not achieved with a single antihypertensive agent, either increase dosage of single drug or add a second drug with demonstrated benefit and preferably a complementary mechanism of action (e.g., ACE inhibitor, angiotensin II receptor antagonist, calcium-channel blocker, thiazide diuretic).Available as bisoprolol fumarate; dosage expressed in terms of the fumarate.Some experts have recommended an initial dosage of 2.5 mg of bisoprolol fumarate and 6.25 mg of hydrochlorothiazide daily.May increase dosage gradually, generally at intervals of ≥2 weeks,Some experts state usual dosage range is 2.5–10 mg once daily.Patients in whom BP is not adequately controlled by monotherapy with bisoprolol fumarate 2.5–20 mg daily or those who respond adequately to a hydrochlorothiazide dosage of 50 mg daily but experience problematic potassium loss can switch to a fixed-combination preparation containing bisoprolol and hydrochlorothiazide.Can use the fixed combination as a substitute for the individually titrated drugs.Alternatively, may initiate antihypertensive therapy with the fixed-combination preparation containing bisoprolol fumarate 2.5 mg and hydrochlorothiazide 6.25 mg daily.If tolerated, increase to 2.5 mg daily for 2–4 weeks; subsequent dosages can be doubled every 2–4 weeks.If deterioration (usually transient) occurs during titration, increase dosage of concurrent diureticReduce dosage in patients with heart failure who experience symptomatic bradycardia (e.g., dizziness) or 2nd or 3rd degree heart block.Some experts have stated that the maximum dosage is 10 mg of bisoprolol fumarate and 6.25 mg of hydrochlorothiazide daily.Dosage generally should not exceed bisoprolol fumarate 20 mg and hydrochlorothiazide 12.5 mg daily.Maximum dosage recommended by ACCF and AHA: 10 mg once daily.Hepatitis or cirrhosis: Initially 2.5 mg once daily.Hemodialysis: Apparently not removed by dialysis; supplemental dose is not required after dialysis;Bisoprolol/hydrochlorothiazide fixed combination: Discontinue if progressive renal impairment develops.Dosage adjustment not required unless appreciable renal or hepatic impairment is present.Patients with sinus bradycardia, heart block greater than first degree, cardiogenic shock, or overt heart failure.Hypersensitivity to bisoprolol fumarate, any ingredient in the formulation, or sulfonamides.Adequate treatment (e.g., with a cardiac glycoside and/or diuretic) and close observation recommended if signs or symptoms of impending heart failure occur; if heart failure continues, discontinue therapy, gradually if possible.Abrupt discontinuance of therapy is not recommended as it may exacerbate symptoms or precipitate MI or ventricular arrhythmias in patients with CAD.Possible precipitation or aggravation of symptoms of arterial insufficiency; use with caution.Generally should not be used in patients with bronchospastic disease,Administer the lowest effective dosage (initially 2.5 mg once daily);Use with caution in patients undergoing major surgery involving general anesthesia.Possible decreased signs and symptoms of hypoglycemia (e.g., tachycardia).Use with caution in patients with diabetes mellitus receiving hypoglycemic drugs.Signs of hyperthyroidism (e.g., tachycardia) may be masked.Possible increased reactivity to repeated, accidental, diagnostic, or therapeutic challenges with a variety of allergens while taking β-blockers.Shares the toxic potentials of β-blockers; observe the usual precautions of these agents.Not known whether bisoprolol fumarate is distributed into human milk.Safety and efficacy profiles in geriatric individuals are similar to those in younger adults.In patients with hepatitis or cirrhosis, reduce initial dosage and adjust dosage cautiously.Fatigue, headache, diarrhea, peripheral edema, and upper respiratory tract infection.Catecholamine-depleting drugs (e.g., reserpine, guanethidine)Monitor closely for excessive decreases in sympathetic activityCalcium-channel blocking agents (e.g., verapamil, diltiazem])Potential for additive negative effects on AV nodal conductionNo clinically important pharmacokinetic interactionβ-Adrenergic blockade may exacerbate rebound hypertension which may occur following clonidine discontinuance Discontinue β-blockers several days before withdrawal of clonidine No clinically important pharmacokinetic interactionPotential for additive negative effects on AV nodal conductionMyocardial depressant general anesthetics (e.g., ether, cyclopropane, trichloroethylene)Potential for increased clearance and decreased elimination half-life of bisoprololInitial dosage adjustments of bisoprolol are not necessaryNo clinically important pharmacokinetic interactionNo effect on prothrombin time with stable warfarin dosageIn healthy individuals, decreased tachycardia (exercise- and isoproterenol-induced) occurs within 1–4 hours.In normal individuals, decreased tachycardia generally persists for 24 hours.Excreted in urine as unchanged drug (50%) and as inactive metabolites; less than 2% excreted in feces.In patients with cirrhosis, half-life is more variable and substantially prolonged (range: 8.3–21.7 hours).In geriatrics, half-life slightly increased due to decreased renal function.Inhibits response to adrenergic stimuli by competitively blocking βDecreases resting and exercise-stimulated heart rate and cardiac output, decreases isoproterenol-induced tachycardia, prolongs sinus node recovery time, refractory period of the AV node, and AV nodal conduction (with rapid atrial stimulation).No intrinsic sympathomimetic activity or membrane-stabilizing effect on the heart.Reduces blood pressure by decreasing cardiac output, decreasing sympathetic outflow from the CNS, and or suppressing renin release.Importance of taking medication exactly as prescribed.Importance of not interrupting or discontinuing therapy without consulting clinician.Importance of informing clinician at the first sign or symptom of heart failure, excessive bradycardia, or if any difficulty in breathing occurs.Importance of informing anesthesiologist or dentist that they are receiving bisoprolol therapy prior to undergoing major surgery.Importance of informing patients with diabetes that the drug may mask signs and symptoms of hypoglycemia, including increased heart rate.Importance of avoiding some activities (e.g., operating machinery or driving a motor vehicle or those requiring mental alertness).Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs.Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.Importance of informing patients of other important precautionary information.