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Beta blockers, also spelled β-blockers and also known as β-adrenergic receptor antagonists, 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). They are also widely used to treat high blood pressure, although they are no longer the first choice for initial treatment of most people. There are additional uses as well, like treatment of anxiety.
Beta blockers are competitive antagonists that block the receptor sites for the endogenous epinephrine (adrenaline) and norepinephrine (noradrenaline) on adrenergic beta receptors, of the sympathetic nervous system, which mediates the fight-or-flight response. (2025). 9781573402217, Current Science Group. ISBN 9781573402217 (2025). 9780781757843, Lippincott Williams & Wilkins. ISBN 9780781757843
β-Adrenergic receptors are found on cells of the heart muscles, smooth muscles, , artery, , 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 thereby weaken the effects of stress hormones.
Some beta blockers block activation of all types of β-adrenergic receptors and others are selective for one of the three known types of beta receptors, designated β1, β2, and β3 receptors. β1-Adrenergic receptors are located mainly in the heart and in the kidneys. β2-Adrenergic receptors are located mainly in the lungs, gastrointestinal tract, liver, uterus, vascular smooth muscle, and skeletal muscle. β3-Adrenergic receptors are located in fat cells.
In 1964, James Black synthesized the first clinically significant beta blockers—propranolol and pronethalol; it revolutionized the medical management of angina pectoris and is considered by many to be one of the most important contributions to clinical medicine and pharmacology of the 20th century.
For the treatment of primary hypertension (high blood pressure), meta-analyses of studies which mostly used atenolol have shown that although beta blockers are more effective than placebo in preventing stroke and total cardiovascular events, they are not as effective as diuretics, medications inhibiting the renin–angiotensin system (e.g., ), or calcium channel blockers.
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. 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. Beta blockers counter this inappropriately high sympathetic activity, eventually leading to an improved ejection fraction, despite an initial reduction in ejection fraction.
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. 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.
Therapeutic administration of beta blockers for congestive heart failure ought to begin at very low doses ( 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. (2025). 9781259584732, McGraw-Hill. ISBN 9781259584732
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. The review identified that beta blockers likely had little to no impact on short-term all-cause mortality and cardiovascular mortality.
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. 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.
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.. It suggested that the effects of beta blockers are inferior to other anti-hypertensive medications.
It is thought that beta blockers do not directly treat psychological symptoms of anxiety, but can help control physical symptoms such as , and this may interfere with a positive feedback loop to indirectly reduce psychological anxiety. High lipophilicity and hence more Centrally permeable beta blockers like propranolol and hydrophilic and hence peripherally selective beta blockers like atenolol appear to have similar benefits on performance anxiety, suggesting peripheral mediation of their effects. However, there has been little in the way of comparisons of the different types of beta blockers. In any case, 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. Although it is thought that beta blockers may act via peripheral mechanisms, there are also findings from preclinical research of central β-adrenergic receptors mediating anxiety.
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. 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".
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. The review found no suitable evidence to support the current guidelines recommending its use.
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.
Adrenergic antagonists are mostly used for cardiovascular disease. The adrenergic antagonists are widely used for lowering blood pressure and relieving hypertension. Effects of β-Blockers With and Without Vasodilating Properties on Central Blood Pressure, Pucci, G., Ranalli, M. G., Battista, F., & Schillaci, G. (2015). Effects of β-Blockers With and Without Vasodilating Properties on Central Blood Pressure. Hypertension, HYPERTENSIONAHA-115. These antagonists have a been proven to relieve the pain caused by myocardial infarction, and also the infarction size, which correlates with heart rate.
There are few non-cardiovascular uses for adrenergic antagonists. Alpha-adrenergic antagonists are also used for treatment of ureteral stones, pain disorder and , drug withdrawal, and anesthesia.
Beta blockers are used to treat acute cardiovascular toxicity (e.g. in overdose) caused by , for instance caused by amphetamine, methamphetamine, cocaine, ephedrine, and other drugs. Combined α1 and beta blockers like labetalol and carvedilol may be more favorable for such purposes due to the possibility of "unopposed α-stimulation" with selective beta blockers like propranolol and atenolol.
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.
Absolute contraindications:
Relative contraindications, or contraindications specific to certain beta-blockers:
Cautions:
are not contraindicated in those receiving beta blockers.
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.
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 blockers.
Carvedilol therapy is commonly associated with edema. 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.
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.
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.Beta-Adrenoceptor Antagonists (Beta-Blockers);
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. 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.
Beta blockers must not be used in the treatment of selective alpha-adrenergic agonist overdose. The blockade of only beta receptors increases hypertension, reduces coronary blood flow, left ventricular function, and cardiac output and tissue perfusion by means of leaving the alpha-adrenergic system stimulation unopposed. 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. The mixed alpha blocker and beta blocker labetalol is especially useful for treatment of concomitant tachycardia and hypertension induced by methamphetamine. The phenomenon of "unopposed alpha stimulation" has not been reported with the use of beta blockers for treatment of methamphetamine toxicity. 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.
Beta blockers were found to be associated with depression in earlier studies. More lipophilic beta blockers, with greater central effects, were especially implicated. However, subsequent more rigorous studies found no causal relationship of beta blockers with depression and regardless of lipid solubility. A small and significant but inconsistent risk of fatigue was found for non-selective beta blockers however.
Beta blockers, due to their antagonism at β1 adrenergic receptors, inhibit both the synthesis of new melatonin and its secretion by the pineal gland. More lipophilicity beta blockers, with greater ability to cross the blood–brain barrier, are known to be able to suppress melatonin release by 50 to 80%. The neuropsychiatric side effects of some beta blockers (e.g. sleep disruption, insomnia) may be related to this effect.
People experiencing bronchospasm due to the β2 receptor-blocking effects of nonselective beta blockers may be treated with anticholinergic drugs, such as ipratropium, which are safer than beta agonists in patients with cardiovascular disease. Other antidotes for beta blocker poisoning are salbutamol and isoprenaline.
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| Acronyms: ISA = Intrinsic sympathomimetic activity (i.e., partial agonist activity). MSA = Membrane-stabilizing activity (i.e., sodium channel blockade or local anesthetic activity). Notes: Lipophilicity is defined as low = log P <1, moderate = log P 1–3, and high = log P >3 among other definitions. It is a predictor of blood–brain barrier permeability and central effects. Footnotes: a Although labetalol has moderate or high lipophilicity, it appears to nonetheless be peripherally selective. Refs: | |||||||
Beta blockers act as β-adrenergic receptor antagonists. They may be non-selective, antagonizing both the β1- and β2-adrenergic receptors, or they may be selective for antagonism of the β1-adrenergic receptor (often referred to as "cardioselective"). Some beta blockers have intrinsic sympathomimetic activity (ISA), otherwise known as partial agonist activity at the β-adrenergic receptors with weak sympathomimetic effects.
Some beta blockers are not selective for the β-adrenergic receptor and have additional α1-adrenergic receptor antagonism. Some beta blockers have membrane-stabilizing activity, otherwise known as sodium channel blockade or local anesthetic activity. Beta blockers vary in their lipophilicity versus hydrophilicity and hence in their capacity to cross the blood–brain barrier, with some having central nervous system effects and others being peripherally selective.
Beta blockers inhibit these normal epinephrine- and norepinephrine-mediated sympathetic actions, but have minimal effect on resting subjects.
That is, they reduce the effect of excitement or physical exertion on heart rate and force of contraction, (2025). 9780124060616, Elsevier. ISBN 9780124060616 and also tremor, and breakdown of glycogen. Beta blockers can have a constricting effect on the bronchi of the lungs, possibly worsening or causing asthma symptoms. (2025). 9780816051779, Amaranth. ISBN 9780816051779
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.
Accordingly, nonselective beta blockers are expected to have antihypertensive effects. (1997). 9780079129512, Blackwell Science.. ISBN 9780079129512 The primary antihypertensive mechanism of beta blockers is unclear, but may involve reduction in cardiac output (due to negative chronotropic and inotropic effects). 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).
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.
The antiarrhythmic effects of beta blockers arise from sympathetic nervous system blockade—resulting in depression of sinus node function and atrioventricular node conduction, and prolonged atrial 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.
Some beta blockers (e.g. oxprenolol, pindolol, penbutolol, labetalol and acebutolol) exhibit intrinsic sympathomimetic activity (ISA). These agents are capable of exerting low-level receptor 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.
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 pectoris and tachyarrhythmia.
Most beta blockers are lipophilic and can cross into the brain, but there are a number of exceptions. 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. 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. The preceding beta blockers also vary in their intrinsic sympathomimetic activity and β1-adrenergic receptor selectivity (or cardioselectivity), resulting in further differences in pharmacological profiles and suitability in different contexts between them.
The first beta blocker to be developed was dichloroisoprenaline, based on structural modification of the β-adrenergic receptor agonist isoprenaline (isoproterenol). It was described by C. E. Powell and I. H. Slater in 1958. However, dichloroisoprenaline had significant partial agonism and sympathomimetic activity and hence was not a pure antagonist. James Black and John Stephenson described pronethalol (nethalide; ICI-38,174; Alderlin) as a purely antagonistic beta blocker in 1962. But pronethalol suffered from off-target activity and associated and toxicity. As such, it did not enter widespread use and was soon discontinued.
In 1964, Black and colleagues published on propranolol (ICI-45,520; Inderal), which did not have the problems of earlier beta blockers. It was introduced for medical use under the brand name Inderal the same year and became the first widely used beta blocker. Since the introduction of propranolol, there have been three generations of beta blockers with different pharmacological properties, with numerous beta blockers having been developed and introduced for medical use.
For similar reasons, beta blockers have also been used by surgeons. Classical musicians have commonly used beta blockers since the 1970s to reduce stage fright.
Beta blockers have also been used for the treatment of schizoid personality disorder. (1997). 9780789001344, Psychology Press. ISBN 9780789001344 However, there is limited evidence supporting the efficacy of supplemental beta blocker use in addition to antipsychotic drugs for treating schizophrenia.
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