What are the contraindications to beta blockers?

From the Guidelines

Beta blockers are contraindicated in patients with severe bradycardia, high-grade heart block, cardiogenic shock, decompensated heart failure, and severe reactive airway diseases like asthma or COPD, as well as in those with pheochromocytoma without prior alpha blockade, according to the most recent guidelines 1.

Contraindications to Beta Blockers

The following are contraindications to beta blockers:

• Severe bradycardia (heart rate below 50 beats per minute)
• High-grade heart block (second or third degree)
• Cardiogenic shock
• Decompensated heart failure
• Severe reactive airway diseases like asthma or COPD
• Pheochromocytoma without prior alpha blockade
• Advanced degree atrioventricular block for beta blockers in the absence of pacemakers
• Angioedema for ACEi or ARNi

Relative Contraindications

Relative contraindications include:

• Severe peripheral vascular disease or Raynaud's phenomenon
• Diabetic patients who may experience masking of hypoglycemic symptoms
• Patients with severe psychiatric disorders who may experience exacerbation of depression
• Patients with type-1 diabetes who may experience impaired awareness of hypoglycemia

Important Considerations

It is essential to note that true contraindications to beta blockers are rare, and the benefits of beta blockers often outweigh the risks in patients with heart failure or other cardiovascular conditions 1. However, caution should be exercised when initiating beta blockers in patients who have required inotropes during hospitalization, and careful monitoring is necessary to avoid adverse effects such as worsening renal function or symptomatic hypotension 1.

From the FDA Drug Label

PATIENTS WITH BRONCHOSPASTIC DISEASE SHOULD, IN GENERAL, NOT RECEIVE BETA-BLOCKERS. In patients with acute myocardial infarction, cardiac failure which is not promptly and effectively controlled by 80 mg of intravenous furosemide or equivalent therapy is a contraindication to beta-blocker treatment. Good clinical judgment suggests, however, that patients who are dependent on sympathetic stimulation for maintenance of adequate cardiac output and blood pressure are not good candidates for beta-blockade.

The main contraindications to beta blockers are:

• Bronchospastic diseases: Patients with bronchospastic disease should not receive beta-blockers.
• Uncontrolled cardiac failure: Cardiac failure that is not promptly and effectively controlled is a contraindication to beta-blocker treatment.
• Dependence on sympathetic stimulation: Patients who are dependent on sympathetic stimulation for maintenance of adequate cardiac output and blood pressure are not good candidates for beta-blockade. 2

From the Research

Contraindications to Beta Blockers

• Absolute contraindications to beta-blockers include:
  • Severe bradycardia 3
  • Preexisting sick sinus syndrome 3
  • Second- and third-degree atrioventricular block 3
  • Severe left ventricular dysfunction 3
  • Active peripheral vascular disease with rest ischemia 3
  • Reactive airway disease so severe that airway support is required 3
• Relative contraindications to beta-blockers include:
  • Peripheral vascular disease: beta-blockers should be avoided only in those patients with vasospastic disorders, rest pain with severe peripheral vascular disease or nonhealing lesions 4
  • Diabetes mellitus: beta-blockers are not contraindicated in these patients, but some caution should be addressed when signs of autonomic disease are present or in patients with difficult glycemic control 4
  • Chronic obstructive pulmonary disease (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
  • Heart failure: beta-blockers can be used in patients with heart failure, but should be started at a low dose and uptitrated slowly 5
• Other considerations:
  • Beta-blockers can induce bronchospasm in patients with COPD or asthma, but cardioselective beta-blockers and appropriate use of medications such as albuterol can minimize these effects 3
  • Beta-blockers can impair glucose control leading to hypoglycemia in diabetic patients, and post-MI diabetic patients must routinely monitor their blood glucose levels 3
  • Beta-blockers can cause erectile dysfunction, but this is often related to the underlying disease rather than the beta-blocker itself 5