In a patient taking both a beta (beta blocker) blocker and an ACE (angiotensin-converting enzyme) inhibitor, which medication would you decrease first to lower blood pressure?

Decrease the Beta Blocker First

In patients requiring blood pressure reduction while on both a beta blocker and ACE inhibitor, decrease or discontinue the beta blocker first while maintaining the ACE inhibitor. This recommendation is based on the superior cardiovascular and renal protective effects of ACE inhibitors, and the greater propensity of beta blockers to cause symptomatic hypotension, particularly when combined with other antihypertensive agents 1, 2.

Rationale for Prioritizing ACE Inhibitor Maintenance

Cardiovascular and Renal Protection

• ACE inhibitors are foundational therapy for hypertension management and provide proven benefits in reducing cardiovascular events, particularly in patients with diabetes, chronic kidney disease, or established cardiovascular disease 1.
• ACE inhibitors reduce albuminuria and preserve renal function more effectively than other antihypertensive classes 3.
• Both ACC/AHA and ESC/ESH guidelines recommend ACE inhibitors (or ARBs) as first-line agents for most patients with hypertension, particularly those with compelling indications 1.

Beta Blocker Limitations

• Beta blockers are less effective for stroke prevention compared to other antihypertensive classes and are now considered primarily indicated for specific cardiac conditions (heart failure, post-MI, angina) rather than uncomplicated hypertension 1.
• Beta blockers are more likely to cause symptomatic hypotension, bradycardia, and fatigue, especially when combined with ACE inhibitors 1, 2, 4.
• The ESC/ESH guidelines specifically note that beta blockers should be reserved for patients with specific cardiac indications rather than as routine first-line therapy for hypertension 1.

Stepwise Approach to Medication Adjustment

Step 1: Assess Clinical Context

• Determine if the patient has heart failure with reduced ejection fraction (HFrEF), post-MI status, or chronic angina—these are compelling indications for beta blocker continuation 1.
• If HFrEF is present, both medications are Class I recommendations, but the approach differs (see special considerations below) 1.
• Evaluate for volume overload that may be contributing to elevated BP; if present, optimize diuretic therapy first before reducing either agent 1.

Step 2: Initial Beta Blocker Reduction

• Reduce the beta blocker dose by 50% as the first intervention 2.
• Monitor blood pressure and heart rate over 24-48 hours 2.
• The ACC recommends that beta blockers can be administered at different times of day than the ACE inhibitor to minimize additive hypotensive effects if both must be continued 1, 5.

Step 3: Further Adjustment if Needed

• If blood pressure remains elevated after beta blocker reduction, consider temporary discontinuation of the beta blocker while maintaining the ACE inhibitor 2.
• Taper beta blockers rather than abruptly discontinuing to avoid rebound hypertension or tachycardia, particularly in patients with coronary artery disease 1, 2, 6.
• Monitor for rebound tachycardia after beta blocker reduction, which may paradoxically worsen symptoms 2.

Step 4: Reassess and Optimize

• After achieving blood pressure control, reassess whether the beta blocker needs to be reintroduced at a lower dose if there was a compelling cardiac indication 1.
• Consider adding a diuretic or calcium channel blocker if additional blood pressure lowering is needed while maintaining the ACE inhibitor 1.

Special Considerations in Heart Failure

When Both Medications Are Indicated for HFrEF

• In patients with HFrEF on guideline-directed medical therapy (GDMT), both ACE inhibitors and beta blockers are Class I recommendations for mortality reduction 1.
• The 2025 ESC Heart Failure Association consensus specifically addresses this scenario: if blood pressure is low but the patient is asymptomatic with adequate perfusion, maintain both medications at the highest tolerated doses 1.
• If symptomatic hypotension occurs in HFrEF patients, first optimize diuretic therapy to address volume status before reducing either neurohormonal blocker 1.
• The timing of administration can be separated (beta blocker and ACE inhibitor given at different times of day) to minimize peak hypotensive effects 1, 5.

Medication Sequencing in HFrEF with Low BP

• If initiating therapy in a treatment-naïve HFrEF patient with low blood pressure, the ESC recommends starting SGLT2 inhibitors and mineralocorticoid receptor antagonists first (minimal BP effect), then adding low-dose beta blocker or very low-dose sacubitril/valsartan, with gradual uptitration 1.
• This differs from the scenario of reducing established therapy, where beta blocker reduction takes priority in the absence of recent decompensation 1.

Common Pitfalls to Avoid

Do Not Reduce ACE Inhibitor First

• Reducing the ACE inhibitor sacrifices proven cardiovascular and renal protection without addressing the medication more likely to cause symptomatic hypotension 1, 3.
• ACE inhibitors have superior efficacy in preventing strokes and cardiovascular events compared to beta blockers in uncomplicated hypertension 1, 6, 7.

Avoid Abrupt Beta Blocker Discontinuation

• Sudden withdrawal of beta blockers can precipitate rebound hypertension, tachycardia, or acute coronary syndrome in patients with underlying coronary disease 1, 2, 6.
• Always taper beta blockers over several days when discontinuing 2, 6.

Do Not Simultaneously Reduce Both Medications

• Reducing both medications simultaneously may compromise disease management and makes it difficult to determine which agent was causing the problem 2.
• The sequential approach allows for proper assessment of each medication's contribution 2.

Consider Non-Medication Factors

• Evaluate for medications that may be contributing to hypotension that are not indicated for the patient's conditions (calcium channel blockers, alpha blockers, centrally acting agents) and discontinue these first 1.
• Assess for volume depletion from overdiuresis, which may be the primary cause of low blood pressure 1.

Monitoring Parameters

• Blood pressure should be monitored frequently (every 15 minutes initially if symptomatic, then daily) after any medication adjustment 8.
• Heart rate monitoring is essential after beta blocker reduction to detect rebound tachycardia 2.
• Assess for symptoms of hypoperfusion (dizziness, lightheadedness, fatigue, oliguria) rather than relying solely on blood pressure numbers 1.
• In patients with heart failure, monitor for signs of decompensation (edema, dyspnea, weight gain) after medication changes 1.