What are examples of beta blockers (beta-adrenergic blocking agents) that can be used in a patient with Peripheral Arterial Occlusive Disease (PAOD)?

Beta Blockers Safe and Effective in Peripheral Arterial Occlusive Disease (PAOD)

Beta-blockers can be prescribed to patients with PAOD, including those with intermittent claudication, as they do not worsen walking capacity or limb events and are effective antihypertensive agents. 1, 2

Key Beta Blocker Examples for PAOD Patients

Cardioselective Beta-1 Blockers (Preferred)

These agents are preferred in PAOD because they have less effect on peripheral vasculature:

• Bisoprolol: 2.5–10 mg once daily 1

  • Preferred in heart failure with reduced ejection fraction (HFrEF) 1
  • Demonstrated perioperative cardiac protection in vascular surgery patients 3

• Metoprolol succinate (extended-release): 50–200 mg once daily 1

  • Preferred formulation in HFrEF and post-MI patients 1
  • Avoid abrupt cessation 1

• Metoprolol tartrate: 100–200 mg twice daily 1

  • Immediate-release formulation requiring twice-daily dosing 1

• Atenolol: 25–100 mg twice daily 1

  • Cardioselective but not preferred in HFrEF 1

• Betaxolol: 5–20 mg once daily 1

  • Preferred in bronchospastic airway disease requiring a beta blocker 1

• Nebivolol: 5–40 mg once daily 1

  • Cardioselective with vasodilatory properties through nitric oxide-induced vasodilation 1
  • Avoid abrupt cessation 1

Combined Alpha- and Beta-Receptor Blockers

• Carvedilol: 12.5–50 mg twice daily 1

  • Preferred in HFrEF patients 1
  • Vasodilatory properties may be advantageous in PAOD 4
  • Avoid abrupt cessation 1

• Carvedilol phosphate: 20–80 mg once daily 1

  • Extended-release formulation 1

• Labetalol: 200–800 mg twice daily 1

Non-Cardioselective Beta Blockers (Use with Caution)

• Nadolol: 40–120 mg once daily 1

  • Avoid in reactive airways disease 1

• Propranolol IR: 80–160 mg twice daily 1

  • Avoid abrupt cessation 1

• Propranolol LA: 80–160 mg once daily 1

Beta Blockers with Intrinsic Sympathomimetic Activity (Generally Avoid)

• Acebutolol: 200–800 mg twice daily 1

  • Generally avoid, especially in IHD or HF 1

• Penbutolol: 10–40 mg once daily 1

  • Avoid abrupt cessation 1

• Pindolol: 10–60 mg twice daily 1

Clinical Context and Evidence

Historical Misconception Now Corrected

Beta-blockers were historically considered contraindicated in PAOD, but multiple studies have demonstrated this concern is unfounded. 5, 4, 6 Research from the 1980s-1990s established that cardioselective beta-1 blockers do not significantly impair peripheral blood flow or worsen claudication symptoms. 5

Specific Indications in PAOD Patients

When beta-blockers are particularly indicated:

• Hypertension requiring treatment 1, 2
• Concurrent ischemic heart disease (IHD) 1
• Heart failure with reduced ejection fraction 1
• Post-myocardial infarction (should be continued for at least 3 years) 1
• Perioperative cardiac protection in high-risk vascular surgery 3, 7

Beta-blockers are NOT first-line antihypertensive agents in PAOD unless concurrent IHD or HF exists. 1 ACE inhibitors or ARBs should be considered as first-line antihypertensive therapy in PAOD patients. 1

Important Caveats and Contraindications

Absolute contraindications:

• Advanced heart block without pacemaker 1
• Significant bradycardia or hypotension 1
• Active asthma or reactive airways disease 1
• Decompensated heart failure or cardiogenic shock 1, 3
• Recent cocaine or methamphetamine use with acute intoxication 1

Use with extreme caution in:

• Critical limb ischemia (pain at rest and/or necroses) 4
• Patients requiring careful blood pressure management to maintain poststenotic perfusion 4

Never abruptly discontinue beta-blockers - taper to avoid rebound hypertension and increased cardiac risk. 1

Preferred Agents Based on Comorbidities

For PAOD + Heart Failure: Bisoprolol, metoprolol succinate, or carvedilol are the only beta-blockers proven to reduce mortality. 1

For PAOD + Post-MI: Any beta-blocker for 3 years minimum, but bisoprolol, carvedilol, or metoprolol succinate preferred if concurrent left ventricular systolic dysfunction. 1

For PAOD + Bronchospastic Disease: If beta-blocker absolutely necessary, use cardioselective agents (bisoprolol, metoprolol, atenolol, betaxolol). 1

For PAOD + Perioperative Vascular Surgery: Bisoprolol started at least 7 days preoperatively, titrated to heart rate 60 bpm, continued 30 days postoperatively. 3