Beta blocker

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Beta blockers, also spelled β-blockers, are a class of medications that are predominantly used to manage abnormal heart rhythms (

high blood pressure, although they are no longer the first choice for initial treatment of most patients.[2]

Beta blockers are

β-adrenergic receptors and others are selective for one of the three known types of beta receptors, designated β1, β2 and β3 receptors.[3]: 153  β1-adrenergic receptors are located mainly in the heart and in the kidneys.[4] β2-adrenergic receptors are located mainly in the lungs, gastrointestinal tract, liver, uterus, vascular smooth muscle, and skeletal muscle.[4] β3-adrenergic receptors are located in fat cells.[5]

Beta receptors are found on cells of the

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,

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]

For the treatment of primary hypertension,

calcium channel blockers.[9][10][11][12]

Medical uses

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.

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

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

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

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]

Performance-enhancing use

Because they promote lower heart rates and reduce tremors, beta blockers have been used in professional sports where high accuracy is required, including archery, shooting, golf[34] and snooker.[34] Beta blockers are banned in some sports by the International Olympic Committee.[35] In the 2008 Summer Olympics, 50-metre pistol silver medalist and 10-metre air pistol bronze medalist Kim Jong-su tested positive for propranolol and was stripped of his medals.[36]

For similar reasons, beta blockers have also been used by surgeons.[37]

Classical musicians have commonly used beta blockers since the 1970s to reduce stage fright.[38]

Adverse effects

hallucinations, insomnia, nightmares, sexual dysfunction, erectile dysfunction, alteration of glucose and lipid metabolism.[medical citation needed] Mixed α1/β-antagonist therapy is also commonly associated with orthostatic hypotension
. Carvedilol therapy is commonly associated with edema.[39][page needed] Due to the high penetration across the blood–brain barrier, lipophilic beta blockers, such as propranolol and metoprolol, are more likely than other less lipophilic beta blockers to cause sleep disturbances, such as insomnia, vivid dreams and nightmares.[40]

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 hormone glucagon, 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

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

alpha blockers such as phentolamine.[46]

Contraindications and cautions

Absolute contraindications:

Relative contraindications, or contraindications specific to certain beta-blockers:

  • Long QT syndrome: sotalol is contraindicated
  • History of torsades de pointes: sotalol is contraindicated

Cautions:

Asthma

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.

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

diaphoresis
, and tremors. Diligent blood glucose level monitoring is necessary for a patient with diabetes mellitus on beta blocker.

Hyperthyroidism

Abrupt withdrawal can result in a thyroid storm.[47]

Bradycardia or AV block

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

pharmacological therapy
.

People experiencing bronchospasm due to the β2 receptor-blocking effects of nonselective beta blockers may be treated with

ipratropium, which are safer than beta agonists in patients with cardiovascular disease. Other antidotes for beta blocker poisoning are salbutamol and isoprenaline
.

Pharmacology

Intrinsic sympathomimetic activity

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.

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

tachyarrhythmia.[39]

β-Adrenergic receptor antagonism

Stimulation of β1 receptors by epinephrine and norepinephrine induces a positive

inotropic effect on the heart and increases cardiac conduction velocity and automaticity.[56] Stimulation of β1 receptors on the kidney causes renin release.[57] Stimulation of β2 receptors induces smooth muscle relaxation,[58] induces tremor in skeletal muscle,[59] and increases glycogenolysis in the liver and skeletal muscle.[60] Stimulation of β3 receptors induces lipolysis.[61]

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]

The antiarrhythmic effects of beta blockers arise from sympathetic nervous system blockade—resulting in depression of

refractory periods. Sotalol, in particular, has additional antiarrhythmic properties and prolongs action potential duration through potassium channel
blockade.

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.

α1-Adrenergic receptor antagonism

Some beta blockers (e.g., labetalol and carvedilol) exhibit mixed antagonism of both β- and α1-adrenergic receptors, which provides additional arteriolar vasodilating action.[68][69]

Blood–brain barrier permeability

Beta blockers vary in their

visual hallucinations, delirium, psychosis, Parkinson's disease, and falling.[70] Conversely, central nervous system-related benefits of beta blockers may include prevention and treatment of migraine, essential tremor, akathisia, anxiety, post-traumatic stress disorder, aggression, and obsessive–compulsive disorder.[70]

Most beta blockers are lipophilic and can cross into the brain, but there are a number of exceptions.

intrinsic sympathomimetic activity and β1-adrenergic receptor selectivity (or cardioselectivity), resulting in further differences in pharmacological profiles and suitability in different contexts between them.[70]

Agents

Dichloroisoprenaline, the first beta blocker

Nonselective agents

Nonselective beta blockers display both β1 and β2 antagonism.[74]

β1-selective agents

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.

Nebivolol and bisoprolol are the most β1 cardioselective beta blockers.[80]

β2-selective agents

β3-selective agents

β1 selective antagonist and β3 agonist agents

Comparative information

Pharmacological differences

  • Agents with intrinsic sympathomimetic action (ISA)
  • Agents organized by lipid solubility (lipophilicity)[86]
    • High lipophilicity: propranolol, labetalol
    • Intermediate lipophilicity: metoprolol, bisoprolol, carvedilol, acebutolol, timolol, pindolol
    • Low lipophilicity (also known as hydrophilic beta blockers): atenolol, nadolol, and sotalol
  • Agents with membrane stabilizing effect[87]
    • Carvedilol, propranolol > oxprenolol > labetalol, metoprolol, timolol

Indication differences

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]

Contrast agents are not contraindicated in those receiving beta blockers.[102]

See also

  • Alpha blockers

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External links
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