Modes of action and cardiovascular effects
- Modes of action: beta-blockers antagonise the effect of beta-adrenergic stimuli .
- Cardiovascular effects: beta-blockers reduce heart rate, cardiac contractility, and systolic blood pressure. They also have anti-arrhythmic effects since they decrease spontaneous firing of ectopic pacemakers, slow conduction, and increase the refractory period of the atrioventricular (AV) node .
- Classification: beta-blockers can be classified as non-selective (combined β1 and β2 blockers) or cardioselective β1-antagonists (see Table 1).
Acute coronary syndrome
- Beta-blockers reduce mortality and reinfarction by 20-25% in those who have recovered from an infarction .
- Oral treatment with beta-blockers should be considered for all ST-elevation myocardial infarction (STEMI) patients without contraindications (Class IIa, Level B) . They are indicated if STEMI patients also have heart failure or LV dysfunction (Class I, Level A) .
Stable coronary artery disease
- Beta-blockade is a very effective symptomatic treatment, alone or combined with another drug, for most of patients with classical angina .
- Beta-blockers and/or calcium channel blockers are first-line treatment to control heart rate and anginal symptoms (Class I, Level A) .
- Beta-blockers have been shown to reduce mortality and heart failure readmissions in patients with heart failure with a reduced ejection fraction (HFrEF) .
- Beta-blockers are recommended, in addition to ACE inhibitors, for patients with stable, symptomatic HFrEF (Class I, Level A) .
- Bisoprolol, Carvedilol, Metoprolol and Nebivolol are licensed for use in HFrEF and should be preferred .
- Beta-blockers can be used to slow the heart rate in patients with arrhythmias such as atrial flutter and/or atrial fibrillation .
- They are effective in the control of ventricular arrhythmias related to sympathetic activation, acute coronary syndrome, and heart failure; including the prevention of sudden cardiac death .
Contraindications and side effects
- The most frequent side effects of beta-blockers include: hypotension, bradycardia, bronchospasm, cold extremities, fatigue, headache, sleep disturbances and increased insulin resistance .
- High-degree AV block is an absolute contraindication (if no pacemaker) .
- Use cardioselective beta-blockers in case of chronic obstructive pulmonary disease (COPD); start low and go slow .
- Asthma is a relative contraindication for the use of beta-blockers . These drugs should be used with caution and preferably with specialist advice.
Types and typical dosages of the most frequently used beta-blockers .
|Name||Average daily oral dose|
|Pindolol||10-40 mg twice a day|
|Propanolol||40-160 mg twice a day|
|Sotalol||80-160 mg twice a day|
|Timolol||5-40 mg twice a day|
|Carvedilol||25 mg once/twice a day|
|Atenolol||25-100 mg once a day|
|Bisoprolol||2.5-10 mg once a day|
|Celiprolol||200-600 mg once a day|
|Metoprolol||50-200 mg once/twice a day|
|Nebivolol||2.5-10 mg once a day|
Practical recommendations for the use of beta-blockers in daily practice 
- Beta-blockers are very effective for the symptomatic treatment of patients with effort angina or arrhythmias.
- Most evidence for the reduction of cardiovascular events by beta-blockers concerns acute coronary syndrome patients; especially in the presence of LV dysfunction.
- High-degree AV block (without a pacemaker) is an absolute contraindication.
- Asthma is a relative contraindication.
- COPD is a relative contraindication.
- Start low and go slow with the elderly, COPD, and patients with heart failure.
- The most frequent side effects include: hypotension, bronchospasm, central effects, and increased insulin resistance.
- In case of HFrEF: Use evidence-based beta-blockers: carvedilol, bisoprolol, metoprolol, nebivolol.
- In case of HFrEF: Start low and go slow (up-titration after at least 2 weeks).
- In case of HFrEF: In case of an episode of exacerbation of heart failure, start after clinical stabilization only.