From the Guidelines
Beta blockers should not be given to patients with certain conditions that could lead to serious adverse effects, including severe bradycardia, high-grade heart block, cardiogenic shock, and decompensated heart failure, as stated in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.
Contraindications to Beta Blockers
The following conditions are considered absolute contraindications to beta blocker therapy:
- Severe bradycardia (heart rate below 50 beats per minute)
- High-grade heart block (second or third degree)
- Cardiogenic shock
- Decompensated heart failure These conditions can lead to serious adverse effects, including decreased cardiac output and increased risk of shock, as noted in the 2014 AHA/ACC guideline 1.
Relative Contraindications
Relative contraindications to beta blocker therapy include:
- Asthma
- COPD
- Peripheral vascular disease
- Diabetes (especially those prone to hypoglycemia)
- Depression In these cases, beta blockers should be used with caution, and the benefits and risks of therapy should be carefully weighed, as recommended in the 2014 AHA/ACC guideline 1.
Specific Considerations
Specific beta blockers, such as propranolol and metoprolol, may be more likely to exacerbate bronchospasm in respiratory conditions, while cardioselective agents, such as bisoprolol, may be safer options when treatment is necessary, as noted in the ACC/AHA UA/NSTEMI guideline revision 1.
Guideline Recommendations
The 2014 AHA/ACC guideline recommends that oral beta-blocker therapy should be initiated within the first 24 hours in patients who do not have any contraindications to beta blockade, and that patients with concomitant NSTE-ACS, stabilized HF, and reduced systolic function should continue beta-blocker therapy with one of the three drugs proven to reduce mortality in patients with HF: sustained-release metoprolol succinate, carvedilol, or bisoprolol 1.
From the FDA Drug Label
CONTRAINDICATIONS Hypersensitivity to metoprolol and related derivatives, or to any of the excipients; hypersensitivity to other beta-blockers (cross sensitivity between beta-blockers can occur). Myocardial Infarction Metoprolol is contraindicated in patients with a heart rate < 45 beats/min; second- and third-degree heart block; significant first-degree heart block (P-R interval ≥ 0.24 sec); systolic blood pressure < 100 mmHg; or moderate-to-severe cardiac failure PATIENTS WITH BRONCHOSPASTIC DISEASE SHOULD, IN GENERAL, NOT RECEIVE BETA-BLOCKERS.
The main contraindications to give beta blockers are:
- Hypersensitivity to beta-blockers or their excipients
- Cardiac conditions such as:
- Heart rate < 45 beats/min
- Second- and third-degree heart block
- Significant first-degree heart block (P-R interval ≥ 0.24 sec)
- Systolic blood pressure < 100 mmHg
- Moderate-to-severe cardiac failure
- Bronchospastic diseases, although atenolol may be used with caution in certain cases 2 It is also important to note that beta blockers should be used with caution in patients with diabetes and thyrotoxicosis 2. In patients with coronary artery disease, beta blockers should not be discontinued abruptly 2. 3
From the Research
Contraindications to Beta Blockers
- Traditional contraindications to beta-blockers include peripheral vascular diseases, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and asthma 4
- However, recent data suggest that the rigorous application of these rules may not be completely justified, and many patients may be inappropriately excluded from the beneficial effects of beta-blocker therapy 4
Specific Contraindications
- Peripheral vascular disease: beta-blockers should be avoided only in patients with vasospastic disorders, rest pain with severe peripheral vascular disease, or nonhealing lesions 4
- Diabetes mellitus: beta-blockers are not contraindicated in patients with diabetes, but caution should be exercised when signs of autonomic disease are present or in patients with difficult glycemic control 4
- COPD and asthma: beta-blockers are contraindicated in patients with a history of asthma, moderate to severe COPD, or those on chronic bronchodilator treatment 4, 5
Individual Beta Blocker Contraindications
- Contraindications differ widely among beta blockers and should be cited for an individual drug, not for the entire class 6
- For example, propranolol and carvedilol are contraindicated in chronic obstructive lung disease, but nebivolol and bisoprolol are not 6
Use of Beta Blockers in Asthma
- Non-selective beta-blockers should not be prescribed for patients with asthma, while cardio-selective beta-blockers may be used when strongly indicated and other therapeutic options are not available 5
- The long-term use of certain beta blockers may be useful in the treatment of asthma under certain circumstances, but this has not been fully evaluated 7