Oral beta blockers and calcium channel blockers for management of premature ventricular complexes in high-risk or symptomatic adult patients

Medication name	Initial dose	Maximum dose	Other considerations
Beta blockers
Metoprolol IR	25 mg twice daily	400 mg daily in 2 or 3 divided doses (doses higher than 100 mg twice daily are rarely used)	Commonly used
Metoprolol succinate ER	50 mg once daily	400 mg daily (doses higher than 200 mg once daily are rarely used)	May be used in patients with HFrEF at lower initial dose of 12.5 to 25 mg once daily
Carvedilol IR	3.125 mg twice daily	25 mg twice daily	Commonly used; may be used in patients with HFrEF
Bisoprolol	2.5 mg once daily	10 mg once daily
Nebivolol	5 mg once daily	40 mg once daily	Lower doses of 1.25 to 10 mg to be used in patients with HF
Atenolol	25 mg once daily	200 mg once daily (doses higher than 100 mg once daily are rarely used)	Avoid in patients with HF
Nadolol	40 mg once daily	120 mg daily	Avoid in patients with HF; first-choice therapy in some channelopathies
Betaxolol	5 mg once daily	20 mg once daily	Avoid in patients with HF
Propranolol IR	10 mg two or three times daily	80 mg daily twice daily	Avoid in patients with HF; first-choice therapy in some channelopathies and in hyperthyroidism
Propranolol LA	80 mg once daily	160 mg once daily	Avoid in patients with HF; first-choice therapy in some channelopathies and in hyperthyroidism
Calcium channel blockers*
Diltiazem (12-hour)	60 mg twice daily	180 mg twice daily
Diltiazem ER (24-hour)	120 mg once daily	360 mg once daily
Verapamil IR	40 or 80 mg three times daily	120 mg three times daily
Verapamil ER	120 or 180 mg once daily	360 mg once daily or 180 mg twice daily

Initial and usual maximal dosages for reduction of PVC burden. Initial dose may be titrated (eg, at two-week intervals) as necessary for reduction in symptoms that correspond with a reduction in PVCs; refer to UpToDate topic review of PVC treatment and prognosis for additional information, including patient selection and monitoring.

IR: immediate release; ER: extended release; LA: long acting; HFrEF: heart failure with reduced ejection fraction; PVC: premature ventricular complex.

* In patients without reduced left ventricular ejection fraction or structural heart disease, a non-dihydropyridine calcium channel blocker can be substituted if beta blockers are not tolerated or are not successful in reducing symptoms. Patients with a cardiomyopathy, with or without HF symptoms, should not be treated with calcium channel blocker.

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Oral beta blockers and calcium channel blockers for management of premature ventricular complexes in high-risk or symptomatic adult patients