Do selective beta blockers (beta-adrenergic blocking agents) cause less dyspnea (shortness of breath)?

From the Guidelines

Selective beta blockers generally cause less dyspnea than non-selective beta blockers, particularly in patients with respiratory conditions like asthma or COPD, as they primarily target beta-1 receptors in the heart with minimal effect on beta-2 receptors in the lungs. This is supported by a recent study published in 2022 in the journal Hypertension, which found that beta 1-selective beta-blockers may even reduce COPD exacerbations 1. The study also noted that cardio-selective beta-blockers do not affect the action of bronchodilators but reduce the heart rate acceleration caused by their use.

Some key points to consider when prescribing selective beta blockers include:

• They should be used cautiously with appropriate monitoring, especially when initiating therapy or increasing doses
• They are preferred for patients with both cardiovascular disease and respiratory conditions
• Even with selective agents, some patients may experience mild dyspnea due to reduced cardiac output rather than bronchospasm
• Beta-1 selective beta blockers, such as metoprolol, bisoprolol, and atenolol, are good options for patients with respiratory conditions
• Non-selective beta blockers, such as propranolol, carvedilol, and nadolol, should be avoided in patients with respiratory conditions due to their potential to cause bronchospasm and breathing difficulties.

It's also worth noting that a study published in 2014 in the journal Circulation found that beta blockers without increased sympathomimetic activity should be administered orally in the absence of contraindications, and that beta-1 selective beta blockers are preferred in patients with chronic obstructive lung disease or a history of asthma 1. However, the most recent and highest quality study on this topic is the 2022 study published in Hypertension, which provides the most up-to-date guidance on the use of selective beta blockers in patients with respiratory conditions 1.

From the FDA Drug Label

Pulmonary function studies have been conducted in healthy volunteers, asthmatics, and patients with chronic obstructive pulmonary disease (COPD). Doses of bisoprolol fumarate ranged from 5 to 60 mg, atenolol from 50 to 200 mg, metoprolol from 100 to 200 mg, and propranolol from 40 to 80 mg In some studies, slight, asymptomatic increases in airways resistance (AWR) and decreases in forced expiratory volume (FEV 1) were observed with doses of bisoprolol fumarate 20 mg and higher, similar to the small increases in AWR also noted with the other cardioselective beta-blockers.

Relative beta 1 selectivity is demonstrated by the following: (1) In healthy subjects, metoprolol is unable to reverse the beta 2-mediated vasodilating effects of epinephrine This contrasts with the effect of nonselective (beta 1 plus beta 2) beta-blockers, which completely reverse the vasodilating effects of epinephrine. (2) In asthmatic patients, metoprolol reduces FEV 1 and FVC significantly less than a nonselective beta-blocker, propranolol, at equivalent beta 1-receptor blocking doses

Selective beta blockers may cause less dyspnea compared to non-selective beta blockers due to their beta 1 selectivity, which means they have a lower affinity for beta 2 receptors found in the lungs. This is supported by studies showing that:

• Bisoprolol fumarate causes slight, asymptomatic increases in airways resistance and decreases in forced expiratory volume at higher doses 2.
• Metoprolol reduces FEV1 and FVC significantly less than a nonselective beta-blocker, propranolol, at equivalent beta 1-receptor blocking doses 3. However, it is essential to note that these effects can vary depending on the individual patient and the specific medication used.

From the Research

Selective Beta Blockers and Dyspnea

• The use of selective beta blockers in patients with chronic obstructive pulmonary disease (COPD) has been studied to assess their effects on respiratory function and symptoms, including dyspnea 4, 5, 6, 7, 8.
• A study published in 2002 found that cardioselective beta blockers did not produce a significant short-term reduction in airway function or in the incidence of COPD exacerbations, suggesting that they may be safe to use in patients with COPD 4.
• Another study published in 2003 found that metoprolol, a beta-1 selective blocker, can be used safely in coronary artery disease patients with COPD, with no significant decrease in forced expiratory volume in 1 second (FEV1) or adverse events 5.
• A review published in 2020 highlighted the importance of considering cardioselective beta blockers as part of the treatment regimen for patients with both heart failure and COPD, as they can help improve survival and reduce symptoms, including dyspnea 6.
• A study published in 2016 found that bisoprolol use was associated with a dose-response survival benefit in patients with coexistent heart failure and COPD, whereas carvedilol and metoprolol did not show a significant survival benefit 7.
• A randomized trial published in 2011 compared the effects of bisoprolol and carvedilol in patients with chronic heart failure and COPD, and found that bisoprolol induced demonstrable improvement in pulmonary function and caused less adverse events, including dyspnea 8.

Comparison of Selective Beta Blockers

• The studies suggest that bisoprolol may be a better option than carvedilol or metoprolol for patients with COPD, as it has been shown to improve pulmonary function and cause fewer adverse events, including dyspnea 7, 8.
• However, the evidence is not conclusive, and more studies are needed to fully understand the effects of selective beta blockers on dyspnea in patients with COPD.
• The use of selective beta blockers in patients with COPD should be individualized, taking into account the patient's specific condition, comorbidities, and response to treatment, as well as careful monitoring of cardiopulmonary function 4, 5, 6, 7, 8.