Bisoprolol in CAD - Key Insights from National Consensus 2025 with Special Focus on Women

Bisoprolol is reaffirmed as a key cardioselective Beta-1-blocker across the cardiovascular disease (CVD) continuum, with a special focus on its clinical utility in women with coronary artery disease (CAD), as reported in a recently released national consensus by Indian experts.

The consensus, published in the May 2025 issue of JAPI, was developed by Indian cardiologists, physicians, and a multispecialty panel through a rigorous review of clinical trials, real-world data, clinical guidelines, and gender-specific considerations. It highlights the need for equitable, evidence-based cardiovascular care and supports greater implementation of β1-selective therapy in women, who are often underrepresented in clinical trials. Below are the key insights from the national consensus:

Cardiovascular Disease in Indian Women

CVD poses a significant yet under-recognized burden among Indian women across all age groups. As the consensus emphasized, “Women bear a significant burden across all age groups, with factors like hormonal changes, obesity, and social barriers requiring tailored approaches.”

CAD presents differently in women compared to men, with more frequent non-obstructive disease, narrower arteries, diffuse atherosclerosis, and atypical symptoms. These factors contribute to underdiagnosis and delayed care. Postmenopausal women are especially vulnerable and experience significantly higher mortality following myocardial infarction (MI).

Despite a lower overall incidence of MI, women experience higher mortality following acute coronary events, partly due to atypical symptoms like fatigue, nausea, or anxiety rather than classic chest pain. Postmenopausal women face elevated risk for heart failure with preserved ejection fraction (HFpEF) and Takotsubo cardiomyopathy due to arterial stiffness and hormonal withdrawal.

Bisoprolol: A First-Line Choice for Women with CAD

The consensus reaffirmed bisoprolol as the preferred β1-selective β-blocker for women with CAD, including stable angina, post-MI care, ST-elevation and non-ST-elevation MI (STEMI/NSTEMI), and atrial fibrillation (AF) with rapid ventricular response. Early initiation at low doses is associated with significant reductions in all-cause mortality, major adverse cardiac events (MACEs), and ventricular arrhythmias (VA).

In women with coexisting heart failure (HF), bisoprolol improves left ventricular ejection fraction (LVEF), survival, and reduces hospitalizations. Its cardioselectivity, metabolic neutrality, and favorable tolerability make it suitable for women with diabetes, asthma, or chronic obstructive pulmonary disease (COPD).

Tailored Utility of Bisoprolol in Comorbidities

Bisoprolol’s pharmacological profile makes it especially valuable for women with multiple chronic conditions. In those with chronic kidney disease (CKD), it offers cardiovascular protection by maintaining blood pressure stability during dialysis—an advantage attributed to its minimal dialyzability.

The drug is well tolerated during pregnancy and lactation under medical supervision, with no developmental harm observed in breastfed infants.

In postmenopausal women, bisoprolol contributes to skeletal health, as it reduces fracture risk through positive effects on BMD and microarchitecture, offering additional value in this high-risk population.

In women with asthma or COPD, bisoprolol’s high β1-selectivity minimizes the risk of bronchospasm, while its metabolic neutrality makes it suitable for those with diabetes or metabolic syndrome, avoiding adverse effects on glucose and lipid profiles.

Diagnostic and Therapeutic Disparities

The consensus highlighted persistent gender-based inequities in CVD care, citing “systemic under-recognition and gender bias in treatment pathways” as key contributors. Women are less likely to receive timely diagnosis or advanced imaging and are underprescribed high-intensity therapies, including β-blockers.

Despite greater benefits from cardiac resynchronization therapy (CRT) in women, referral rates remain low, while higher surgical risks and reduced participation in cardiac rehabilitation continue to compromise outcomes.

Closing the Gender Gap in CAD Care

Despite proven benefits, bisoprolol remains underutilized in women, often due to clinical hesitancy in those with borderline BP or bradycardia. The panel urged a shift toward gender-equitable prescribing and highlighted the need for better female representation in CVD trials. “Gender-equitable diagnosis, guideline-directed treatment, and proactive use of cardioselective agents like bisoprolol can bridge outcome disparities in Indian women,” the report concluded.

References:

1. Chopra HK, Sethi KK, Nair T. et al. National Consensus Statement on Role of Bisoprolol across Cardiovascular Continuum: Special Focus on Women. J Assoc Physicians India 2025;73(5):e16–e33.

2. Procopi N, Zeitouni M, Kerneis M, et al. Beta-blocker interruption effects on blood pressure and heart rate after myocardial infarction: the AβYSS trial. European Heart Journal. 2025;ehaf170. doi:10.1093/eurheartj/ehaf170. Published online May 14, 2025.