What is the best beta (beta blocker) for treating palpitations?

Best Beta Blocker for Palpitations

For palpitations, metoprolol is the preferred beta blocker based on its proven efficacy in achieving heart rate control in 70% of patients and its extensive evidence base across multiple tachyarrhythmias. 1

First-Line Beta Blocker Selection

Metoprolol should be your go-to beta blocker for palpitations, with dosing of 25-100 mg twice daily (immediate release) or 50-400 mg daily (extended release) for ongoing management. 1 This recommendation is supported by the American College of Cardiology and reflects metoprolol's superior track record in rate control across various arrhythmias. 1

Why Metoprolol Over Other Beta Blockers

• Metoprolol has the strongest evidence for maintaining sinus rhythm after conversion of atrial fibrillation, which is often the underlying cause of palpitations. 2
• It is effective both at rest and during exercise, addressing palpitations that occur with exertion. 2
• The risk of proarrhythmia with metoprolol is very low compared to class I antiarrhythmic drugs. 2
• Metoprolol CR/XL formulation provides consistent rate control throughout the day. 2

Alternative Beta Blockers by Clinical Context

For Acute Palpitations (IV Administration)

If intravenous therapy is needed for acute symptomatic palpitations:

• Metoprolol 2.5-10 mg IV bolus over 2 minutes, repeated as required. 3
• Esmolol (0.5 mg/kg IV bolus, then 0.05-0.25 mg/kg/min infusion) for ultra-short acting control if you're uncertain about tolerability. 3

For Specific Arrhythmia Types

For junctional tachycardia causing palpitations:

• Propranolol is specifically recommended (Class IIa) and was found modestly effective in terminating junctional tachycardia in adult case series. 1
• Oral propranolol is preferred for ongoing management of junctional tachycardia due to important proarrhythmic effects of alternative agents. 1

For mitral valve prolapse with palpitations:

• Beta blockers are the treatment of choice for patients with MVP experiencing palpitations associated with mild tachyarrhythmias or increased adrenergic symptoms. 3
• Often cessation of stimulants (caffeine, alcohol, cigarettes) combined with beta blocker therapy is sufficient. 3

Other Beta Blocker Options

The 2016 ESC guidelines list several acceptable beta blockers for rate control: 3

• Bisoprolol: 1.25-20 mg once daily
• Carvedilol: 3.125-50 mg twice daily (avoid in bronchospasm)
• Nebivolol: 2.5-10 mg once daily

However, these lack the specific evidence base that metoprolol has for palpitations and arrhythmia management. 2

Critical Contraindications to Avoid

Never use beta blockers in patients with: 1

• Decompensated heart failure
• Pre-excited atrial fibrillation/flutter (Wolff-Parkinson-White syndrome with tachycardia)
• AV block greater than first degree
• SA node dysfunction
• Severe bronchospasm (though beta-1 selective agents like metoprolol or bisoprolol are safer than carvedilol) 3

When Beta Blockers Are NOT First-Line

If the palpitations are from AVNRT (AV nodal reentrant tachycardia):

• Verapamil or diltiazem are actually preferred over beta blockers (Class I recommendation). 3
• Beta blockers are only Class IIa for AVNRT, as diltiazem is more effective than esmolol for terminating AVNRT. 1

If the patient has reduced ejection fraction (LVEF <40%):

• Beta blockers remain first-line, but avoid diltiazem and verapamil which have negative inotropic effects. 3
• Use metoprolol, bisoprolol, or carvedilol specifically. 3

Monitoring Requirements

• Assess heart rate control both at rest and during activity to ensure adequate symptom control. 1
• Monitor for hypotension, bradycardia (HR <60 bpm), and heart failure exacerbation. 1
• When initiating therapy, avoid excessive dosing that could cause bradyarrhythmias, especially if paroxysmal tachycardia is present. 1

Common Pitfalls

Most common adverse effects include lethargy, headache, peripheral edema, upper respiratory symptoms, gastrointestinal upset, and dizziness. 3 These are generally mild and dose-dependent.

In diabetic patients, beta blockers may mask hypoglycemia symptoms (normally tachycardia from sympathetic activation), so counsel patients accordingly. 1

Combination therapy with digoxin may be needed for refractory cases, but monitor closely for excessive bradycardia. 1