Beta blockers, also spelled β-blockers, are a class of medications that are predominantly used to manage abnormal heart rhythms (
arrhythmia), and to protect the heart from a second
heart attack after a first heart attack (
secondary prevention).[1] They are also widely used to treat
high blood pressure, although they are no longer the first choice for initial treatment of most patients.[2]
Beta receptors are found on cells of the
heart muscles,
smooth muscles,
airways,
arteries,
kidneys, and other tissues that are part of the
sympathetic nervous system and lead to stress responses, especially when they are stimulated by
epinephrine (adrenaline). Beta blockers interfere with the binding to the receptor of epinephrine and other stress hormones and weaken the effects of stress hormones.
In 1964,
James Black[6] synthesized the first clinically significant beta blockers—
propranolol and
pronethalol; it revolutionized the medical management of
angina pectoris[7] and is considered by many to be one of the most important contributions to clinical medicine and
pharmacology of the 20th century.[8]
Beta blockers are utilized in the treatment of various conditions related to the heart and vascular system, as well as several other medical conditions. Common heart-related conditions for which beta blockers are well-established include angina pectoris, acute coronary syndromes, hypertension, and arrhythmias such as atrial fibrillation and heart failure. They are also used in the management of other heart diseases, such as hypertrophic obstructive cardiomyopathy, mitral valve stenosis or prolapse, and dissecting aneurysm. Additionally, beta blockers find applications in vascular surgery, the treatment of anxiety states, cases of thyrotoxicosis, glaucoma, migraines, and esophageal varices.[13]
Congestive heart failure
Although beta blockers were once contraindicated in
congestive heart failure, as they have the potential to worsen the condition due to their effect of decreasing cardiac contractility, studies in the late 1990s showed their efficacy at reducing morbidity and mortality.[14][15][16]Bisoprolol,
carvedilol, and sustained-release
metoprolol are specifically indicated as adjuncts to standard
ACE inhibitor and
diuretic therapy in congestive heart failure, although at doses typically much lower than those indicated for other conditions. Beta blockers are only indicated in cases of compensated, stable congestive heart failure; in cases of acute decompensated heart failure, beta blockers will cause a further decrease in ejection fraction, worsening the patient's current symptoms.[citation needed]
Beta blockers are known primarily for their reductive effect on heart rate, although this is not the only mechanism of action of importance in congestive heart failure.[17] Beta blockers, in addition to their sympatholytic β1 activity in the heart, influence the
renin–angiotensin system at the kidneys. Beta blockers cause a decrease in
renin secretion, which in turn reduces the heart oxygen demand by lowering the
extracellular volume and increasing the oxygen-carrying capacity of the blood. Heart failure characteristically involves increased catecholamine activity on the heart, which is responsible for several deleterious effects, including increased oxygen demand, propagation of inflammatory mediators, and abnormal cardiac tissue remodeling, all of which decrease the efficiency of cardiac contraction and contribute to the low ejection fraction.[18] Beta blockers counter this inappropriately high sympathetic activity, eventually leading to an improved ejection fraction, despite an initial reduction in ejection fraction.[citation needed]
Trials have shown beta blockers reduce the absolute risk of death by 4.5% over a 13-month period. In addition to reducing the risk of mortality, the numbers of hospital visits and hospitalizations were also reduced in the trials.[19] A 2020 Cochrane review found minimal evidence to support the use of beta blockers in congestive heart failure in children, however did identify that from the data available, that they may be of benefit.[20]
Therapeutic administration of beta blockers for congestive heart failure ought to begin at very low doses (1⁄8 of target) with a gradual escalation of the dose. The heart of the patient must adjust to decreasing stimulation by catecholamines and find a new equilibrium at a lower adrenergic drive.[21]
Acute myocardial infarction
Beta blockers are indicated for the treatment of acute
myocardial infarctions. During a myocardial infarction, systemic stress causes an increase in circulating
catecholamines.[22][23] This results an increase in heart rate and blood pressure, therefore increasing myocardial oxygen demand.[23][22] Beta blockers competitively inhibit catecholamines acting on the β1-adrenergic receptors, thus reducing these detrimental effects and resulting in reduced myocardial oxygen consumption and demand.[22]
A 2019 Cochrane review compared beta blockers with
placebo or no intervention, it found that beta blockers probably reduced the short-term risk of reinfarction and the long-term risk of
all-cause mortality and cardiovascular mortality.[22] The review identified that beta blockers likely had little to no impact on short-term all-cause mortality and cardiovascular mortality.[22]
Hypertension
Beta blockers are widely used for the treatment of hypertension.[24]
A 2014 Cochrane review found that in individuals with mild-to-moderate hypertension, non-selective beta blockers led to a reduction of -10/-7mmHg (systolic/diastolic) without increased rates of adverse events.[25] At higher doses, it was found to increase the rate of adverse effects such as a reduction in heart rate, without a corresponding reduction in blood pressure.[25]
A 2017 Cochrane review on the use of beta blockers in hypertension found a modest reduction in cardiovascular disease but little to no change in mortality[26] It suggested that the effects of beta blockers are inferior to other anti-hypertensive medications.[26]
Anxiety
Officially, beta blockers are not approved for
anxiolytic use by the U.S.
Food and Drug Administration.[27] However, many controlled trials in the past 25 years indicate beta blockers are effective in
anxiety disorders, though the mechanism of action is not known.[28] The physiological symptoms of the
fight-or-flight response (pounding heart, cold/clammy hands, increased respiration, sweating, etc.) are significantly reduced, thus enabling anxious individuals to concentrate on the task at hand.[citation needed]
Musicians, public speakers, actors, and professional
dancers have been known to use beta blockers to avoid
performance anxiety,
stage fright, and tremor during both
auditions and public performances. The application to stage fright was first recognized in The Lancet in 1976, and by 1987, a survey conducted by the
International Conference of Symphony Orchestra Musicians, representing the 51 largest orchestras in the United States, revealed 27% of its musicians had used beta blockers and 70% obtained them from friends, not physicians.[29] Beta blockers are inexpensive, said to be relatively safe, and on one hand, seem to improve musicians' performances on a technical level, while some, such as Barry Green, the author of "The Inner Game of Music" and Don Greene, a former Olympic diving coach who teaches Juilliard students to overcome their stage fright naturally, say the performances may be perceived as "soulless and inauthentic".[29]
Surgery
Low certainty evidence indicates that the use of beta blockers around the time of cardiac surgery may decrease the risk of
heart dysrhythmias and
atrial fibrillation.[30] Starting them around the time of other types of surgery, however, may worsen outcomes. For non-cardiac surgery, the use of beta blockers to prevent adverse effects may reduce the risk of atrial fibrillation and myocardial infarctions (very low certainty evidence), however, there is moderate certainty evidence that this approach may increase the risk of hypotension.[31] Low-certainty evidence suggests that beta blockers used perioperatively in non-cardiac surgeries may increase the risk of bradycardia.[31]
Other
A 2014 Cochrane review investigated the use of beta blockers in the maintenance of chronic type B thoracic
aortic aneurysm in comparison to other anti hypertensive medications.[32] The review found no suitable evidence to support the current guidelines recommending its use.[32]
A 2017 Cochrane review on the use of beta blockers to prevent aortic dissections in people with Marfan syndrome was unable to draw definitive conclusions due to lack of evidence.[33]
Adverse effects associated with β2-adrenergic receptor antagonist activity (bronchospasm, peripheral vasoconstriction, alteration of glucose and lipid metabolism) are less common with β1-selective (often termed "cardioselective") agents, but receptor selectivity diminishes at higher doses. Beta blockade, especially of the beta-1 receptor at the
macula densa, inhibits renin release, thus decreasing the release of
aldosterone. This causes
hyponatremia and
hyperkalemia.[citation needed]
Hypoglycemia can occur with beta blockade because β2-adrenoceptors normally stimulate
glycogen breakdown (glycogenolysis) in the liver and pancreatic release of the
hormoneglucagon, which work together to increase plasma glucose. Therefore, blocking β2-adrenoceptors lowers plasma glucose. β1-blockers have fewer metabolic side effects in diabetic patients; however, the fast heart rate that serves as a warning sign for insulin-induced low blood sugar may be masked, resulting in
hypoglycemia unawareness. This is termed
beta blocker-induced hypoglycemia unawareness. Therefore, beta blockers are to be used cautiously in diabetics.[41]
A 2007 study revealed diuretics and beta blockers used for hypertension increase a patient's risk of developing
diabetes mellitus, while
ACE inhibitors and
angiotensin II receptor antagonists (angiotensin receptor blockers) actually decrease the risk of diabetes.[42] Clinical guidelines in Great Britain, but not in the United States, call for avoiding diuretics and beta blockers as first-line treatment of hypertension due to the risk of diabetes.[43]
Beta blockers must not be used in the treatment of selective alpha-adrenergic agonist overdose. The blockade of only beta receptors increases
blood pressure, reduces coronary blood flow, left
ventricular function, and
cardiac output and tissue perfusion by means of leaving the alpha-adrenergic system stimulation unopposed.[medical citation needed] Beta blockers with lipophilic properties and CNS penetration such as
metoprolol and
labetalol may be useful for treating CNS and cardiovascular toxicity from a methamphetamine overdose.[44] The mixed
alpha- and beta blocker labetalol is especially useful for treatment of concomitant tachycardia and hypertension induced by methamphetamine.[45] The phenomenon of "unopposed alpha stimulation" has not been reported with the use of beta blockers for treatment of methamphetamine toxicity.[45] Other appropriate
antihypertensive drugs to administer during hypertensive crisis resulting from stimulant overdose are
vasodilators such as
nitroglycerin,
diuretics such as
furosemide, and
alpha blockers such as
phentolamine.[46]
The 2007 National Heart, Lung, and Blood Institute (
NHLBI) asthma guidelines recommend against the use of non-selective beta blockers in asthmatics, while allowing for the use of cardio selective beta blockers.[48]: 182
Cardio selective beta blocker (β1 blockers) can be prescribed at the least possible dose to those with mild to moderate respiratory symptoms.[49][50]β2-agonists can somewhat mitigate β-blocker-induced
bronchospasm where it exerts greater efficacy on reversing selective β-blocker-induced bronchospasm than the nonselective β-blocker-induced worsening asthma and/or COPD.[49]
Diabetes mellitus
Epinephrine signals early warning of the upcoming
hypoglycemia.[51]
Beta blockers' inhibition on epinephrine's effect can somewhat exacerbate hypoglycemia by interfering with
glycogenolysis and mask signs of hypoglycemia such as tachycardia, palpitations,
diaphoresis, and tremors. Diligent blood glucose level monitoring is necessary for a patient with diabetes mellitus on beta blocker.
Unless a pacemaker is present, beta blockers can severely depress conduction in the AV node, resulting in a reduction of heart rate and cardiac output. One should be very cautious with the use of beta blockers in tachycardia patients with Wolff-Parkinson-White Syndrome, as it can result in life-threatening arrhythmia in certain patients. By slowing the conduction through the AV node, preferential conduction through the accessory pathway is favored. If the patient happens to develop atrial flutter, this could lead to a 1:1 conduction with very fast ventricular rate, or worse, ventricular fibrillation in the case of atrial fibrillation.[citation needed]
Toxicity
Glucagon, used in the treatment of overdose,[52][53] increases the strength of heart contractions, increases intracellular
cAMP, and decreases renal
vascular resistance. It is, therefore, useful in patients with beta blocker cardiotoxicity.[54][55]Cardiac pacing is usually reserved for patients unresponsive to
pharmacological therapy.
Also referred to as intrinsic sympathomimetic effect, this term is used particularly with beta blockers that can show both agonism and antagonism at a given beta receptor, depending on the concentration of the agent (beta blocker) and the concentration of the antagonized agent (usually an endogenous compound, such as norepinephrine). See
partial agonist for a more general description.[citation needed]
Some beta blockers (e.g.
oxprenolol,
pindolol,
penbutolol,
labetalol and
acebutolol) exhibit intrinsic sympathomimetic activity (ISA). These agents are capable of exerting low-level
agonist activity at the β-adrenergic receptor while simultaneously acting as a receptor site
antagonist. These agents, therefore, may be useful in individuals exhibiting excessive
bradycardia with sustained beta blocker therapy.[citation needed]
Agents with ISA should not be used for patients with any kind of angina as it can aggravate or after myocardial infarctions. They may also be less effective than other beta blockers in the management of
angina and
tachyarrhythmia.[39]
Beta blockers inhibit these normal epinephrine- and norepinephrine-mediated
sympathetic actions,[3] but have minimal effect on resting subjects.[citation needed]
That is, they reduce the effect of excitement or physical exertion on heart rate and force of contraction,[62] and also tremor,[63] and breakdown of glycogen. Beta blockers can have a constricting effect on the bronchi of the lungs, possibly worsening or causing asthma symptoms.[64]
Since β2 adrenergic receptors can cause vascular smooth muscle dilation, beta blockers may cause some vasoconstriction. However, this effect tends to be small because the activity of β2 receptors is overshadowed by the more dominant vasoconstricting α1 receptors. By far the greatest effect of beta blockers remains in the heart. Newer, third-generation beta blockers can cause vasodilation through blockade of alpha-adrenergic receptors.[65]
Accordingly, nonselective beta blockers are expected to have antihypertensive effects.[66] The primary antihypertensive mechanism of beta blockers is unclear, but may involve reduction in cardiac output (due to negative chronotropic and inotropic effects).[67] It may also be due to reduction in renin release from the kidneys, and a
central nervous system effect to reduce sympathetic activity (for those beta blockers that do cross the
blood–brain barrier, e.g. propranolol).[citation needed]
Antianginal effects result from negative chronotropic and inotropic effects, which decrease cardiac workload and oxygen demand. Negative
chronotropic properties of beta blockers allow the lifesaving property of heart rate control. Beta blockers are readily titrated to optimal rate control in many pathologic states.[citation needed]
Blockade of the sympathetic nervous system on renin release leads to reduced aldosterone via the
renin–angiotensin–aldosterone system, with a resultant decrease in blood pressure due to decreased sodium and water retention.
Most beta blockers are lipophilic and can cross into the brain, but there are a number of exceptions.[70] Highly lipophilic beta blockers include
penbutolol,
pindolol,
propranolol, and
timolol, moderately lipophilic beta blockers include
acebutolol,
betaxolol,
bisoprolol,
carvedilol,
metoprolol, and
nebivolol, and low lipophilicity or hydrophilic beta blockers include
atenolol,
carteolol,
esmolol,
labetalol,
nadolol, and
sotalol.[70] It is thought that highly lipophilic beta blockers are able to readily cross into the brain, moderately lipophilic beta blockers are able to cross to a lesser degree, and low lipophilicity or hydrophilic beta blockers are minimally able to cross.[70] More lipophilic beta-blockers are known to suppress melatonin release by 50-80%.[71][72][73] The preceding beta blockers also vary in their
intrinsic sympathomimetic activity and
β1-adrenergic receptorselectivity (or cardioselectivity), resulting in further differences in pharmacological profiles and suitability in different contexts between them.[70]
Agents
Nonselective agents
Nonselective beta blockers display both β1 and β2 antagonism.[74]
β1-selective beta blockers are also known as cardioselective beta blockers.[74] Pharmacologically, the beta-blockade of the β1 receptors in the heart will act on
cAMP. The function of cAMP as a second messenger in the cardiac cell is that it phosphorylates the
LTCC and the
ryanodine receptor to increase intracellular calcium levels and cause contraction. Beta-blockade of the β1 receptor will inhibit cAMP from phosphorylating, and it will decrease the ionotrophic and chronotropic effect. Note that drugs may be cardioselective, or act on β1 receptors in the heart only, but still have instrinsic sympathomimetic activity.
Propranolol is the only agent indicated for the control of tremor, portal hypertension, and esophageal variceal bleeding, and used in conjunction with α-blocker therapy in
phaeochromocytoma.[39]
Other effects
Beta blockers, due to their antagonism at beta-1 adrenergic receptors, inhibit both the synthesis of new
melatonin and its secretion by the
pineal gland. The neuropsychiatric side effects of some beta blockers (e.g. sleep disruption,
insomnia) may be due to this effect.[93]
Some pre-clinical and clinical research suggests that some beta blockers may be beneficial for cancer treatment.[94][95] However, other studies do not show a correlation between cancer survival and beta blocker usage.[96][97] Also, a 2017 meta-analysis failed to show any benefit for the use of beta blockers in breast cancer.[98]
Beta blockers have also been used for the treatment of
schizoid personality disorder.[99] However, there is limited evidence supporting the efficacy of supplemental beta blocker use in addition to antipsychotic drugs for treating schizophrenia.[100][101]
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External links
Musicians and beta-blockers by Gerald Klickstein, March 11, 2010 (A blog post that considers "whether beta-blockers are safe, effective, and appropriate for performers to use.")