Beta blockers — A beta blocker without intrinsic sympathomimetic activity should be given after an acute myocardial infarction and to stable patients with heart failure or asymptomatic left ventricular dysfunction (beginning with very low doses to minimize the risk and degree of initial worsening of myocardial function). The use of beta blockers in these settings is in addition to the recommendations for ACE inhibitors in these disorders. (See
"Acute myocardial infarction: Role of beta blocker therapy" and
"Initial pharmacologic therapy of heart failure with reduced ejection fraction in adults", section on 'Beta blocker'.)
Beta blockers are also given for rate control in patients with atrial fibrillation, for control of angina, and for symptom control in a number of other disorders (
table 2).
In the absence of such indications, we and others (including the 2014 statement from the American Society of Hypertension and the International Society of Hypertension [ISH]) recommend that beta blockers
not be used as first-line therapy, particularly in patients over age 60 years [
50,53,74-76]. Compared with other antihypertensive drugs in the primary treatment of hypertension, beta blockers (not all trials used
atenolol) may be associated with inferior protection against stroke risk (particularly among smokers) [
76-78], and perhaps, with atenolol, a small increase in mortality [
79]. These effects are primarily seen in patients over age 60 years [
78,80-82]. Beta blockers are also associated with impaired glucose tolerance and an increased risk of new onset diabetes [
53], with the exception of vasodilating beta blockers such as
carvedilol and
nebivolol [
83,84]. (See
"Treatment of hypertension in patients with diabetes mellitus", section on 'Beta blockers'.)