Beta blockers are a class of antihypertensive medication used to treat hypertension and other heart conditions.1 According to the 2017 hypertension guidelines by the American College of Cardiology (ACC) and American Heart Association (AHA), beta blockers are not recommended as a first-line therapy for adults with hypertension.2 In the 2013 guideline for the management of heart failure, the ACC and AHA recommended beta blockers as a long-term treatment method for patients with heart failure with reduced ejection fraction (HFrEF).3 They recommend appropriate doses of specific beta blockers to decrease the risk of death, hospitalizations, co-morbidities, symptoms, and the presence of coronary artery disease. A 2017 update of the 2013 guideline by the ACC, AHA, and the Heart Failure Society of America reiterated the 2013 recommendation.4 The Joint National Committee also lists heart failure (HF), post-myocardial infarction (MI), high coronary disease risk, and diabetes as compelling indications for beta blockers.5
There are three subclasses of beta blockers (non-selective, beta-1-selective, and beta-1-alpha-selective), and each have different effects depending on how they affect the three adrenergic receptors (beta-1, beta-2, and alpha).6 Beta blockers such as metoprolol, bisoprolol, and carvedilol are preferred in hypertensive patients with HFrEF. Beta blockers with intrinsic sympathomimetic activity, such as acebutolol, penbutolol, and pindolol, are advised against patients with ischemic heart disease or HF.7
Examples of Food and Drug Administration (FDA) approved beta blockers used to treat hypertension:
- Nebivolol8 (beta-1-selective)
- Labetalol9,10 (non-selective)
- Penbutolol11 (non-selective)
Examples of FDA approved beta blockers used to treat other heart conditions, in addition to hypertension:
- Metoprolol (beta-1-selective): used to treat angina pectoris or HF12,13
- Atenolol (beta-1-selective): used to treat angina pectoris due to coronary atherosclerosis, or acute MI14
- Carvedilol (vasodilating non-selective): used to treat mild-to-severe HF, or left ventricular dysfunction following MI in clinically stable patients15,16
- Acebutolol (beta-1-selective): used to treat ventricular arrhythmias17
- Propranolol (non-selective): used to treat angina pectoris due to coronary atherosclerosis, atrial fibrillation, MI, migraine, essential tremor, hypertrophic subaortic stenosis, and pheochromocytoma18
A drug class review compared the use of various beta blockers in hypertensive patients and found equivalent, significant reductions in blood pressure.4 Systematic reviews and meta-analyses also analyzed studies of beta blockers used in hypertensive patients.19,20 One meta-analysis included seven trials of beta blockers (e.g., propranolol, oxprenolol, atenolol, metoprolol, pindolol) on 27,433 participants with primary hypertension. The study found that beta blockers, compared to placebo or no treatment, reduced the risk of stroke by 19% (95% confidence interval [CI] [7 – 29]), with no significant effect on MI or mortality.19 However, when compared to other drugs (e.g., hydrochlorothiazide or other diuretics), the relative risk of stroke was 16% higher for beta blockers (95% CI [4 – 30]). Another review followed up on the previous meta-analysis, reporting findings on 13 randomized clinical trials with 91,561 hypertensive participants.20 Beta blockers (e.g. atenolol, oxprenolol, propranolol, metoprolol), compared to placebo or no treatment, significantly reduced the risk of stroke (relative risk [RR] 0.80, 95% CI [0.66 – 0.96]) and total cardiovascular events (RR 0.88, 95% CI [0.79 – 0.97]). The authors reported this as a modest 20% reduction in stroke and a marginal 12% reduction in cardiovascular events.
References
- U.S. National Library of Medicine. Beta Blockers (Beta-Adrenergic Antagonists). PubMed Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0025465/. Accessed October 2, 2018.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018; 71 (19): e127-e248.
- Writing Committee M, Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128(16):e240-327.
- Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136(6):e137-e161.
- Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572.
- Helfand M, Peterson K, Christensen V, Dana T, Thakurta S. Drug Class Reviews. In: Drug Class Review: Beta Adrenergic Blockers: Final Report Update 4. Portland (OR): Oregon Health & Science University, Portland, Oregon.; 2009.
- PubMed Clinical Q&A [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2008-2013. Available from: https://www.ncbi.nlm.nih.gov/books/NBK62349/.
- Bystolic [package insert]. St. Louis, MO: Forest Pharmaceuticals Inc.; 2011.
- Trandate [package insert]. Oakville, ON: Prometheus Laboratories Inc.; 2010.
- Trandate Injection [package insert]. San Diego, CA: Prometheus Laboratories Inc.; 2010.
- Levatolol [package insert]. Smyrna, GA: Schwarz Pharma; 2010.
- Metoprolol succinate extended-release tablets [package insert]. Sodertalje, Sweden:AstraZeneca AB; 2006.
- Lopressor [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2008.
- Tenormin [package insert]. Conovanas, PR: AstraZeneca Pharmaceuticals LP; 2011.
- Coreg CR [package insert]. Ciales, PR: GK Pharmaceuticals Contract Manufacturing Operations; 2008.
- Coreg [package insert]. Ciales, PR: GK Pharmaceuticals Contract Manufacturing Operations; 2008.
- Sectral [package insert]. Bridgewater, NJ: Reddy Pharmaceuticals; 2007.
- Inderal [package insert]. Cranford, NJ: Akrimax Pharmaceuticals; 2010.
- Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet (London, England). 2005;366(9496):1545-1553.
- Bradley HA, Wiysonge CS, Volmink JA, Mayosi BM, Opie LH. How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Systematic review and meta-analysis. J Hypertens. 2006;24(11):2131-2141.
