What are the target blood pressure and heart rate ranges for home management while taking propranolol (beta blocker)?

From the Guidelines

For home management while taking propranolol, monitoring both blood pressure and heart rate is recommended, with a target blood pressure of less than 130/80 mmHg, as suggested by the 2019 ACC/AHA guideline 1.

Key Considerations

• Check your blood pressure and heart rate at least once daily, ideally at the same time each day, and record the readings.
• Use an automated blood pressure monitor with an arm cuff for accuracy.
• Take measurements while seated with your arm supported at heart level after resting for 5 minutes.
• If your heart rate consistently falls below 50 beats per minute, or if your blood pressure drops below 90/60 mmHg, contact your healthcare provider.
• Similarly, seek medical attention if your blood pressure exceeds 180/120 mmHg.

Rationale

Propranolol works by blocking beta receptors in the heart, reducing heart rate and the force of contractions, which lowers blood pressure. Regular monitoring helps ensure the medication is working effectively without causing excessive slowing of your heart rate or lowering your blood pressure too much, as noted in the management of patients with liver cirrhosis 1.

Additional Guidance

• The 2020 International Society of Hypertension global hypertension practice guidelines recommend evaluating patients for and educating caregivers about potential adverse effects of propranolol, including sleep disturbances, bronchial irritation, and clinically symptomatic bradycardia and hypotension 1.
• The 2023 ACC/AHA/ACCp/HRS guideline for the diagnosis and management of atrial fibrillation provides guidance on the use of beta-blockers, including propranolol, for rate control in patients with atrial fibrillation 1.

From the FDA Drug Label

In a retrospective, uncontrolled study, 107 patients with diastolic blood pressure 110 to 150 mmHg received propranolol 120 mg t.i. d. for at least 6 months, in addition to diuretics and potassium, but with no other hypertensive agent. Propranolol contributed to control of diastolic blood pressure, but the magnitude of the effect of propranolol on blood pressure cannot be ascertained Four double-blind, randomized, crossover studies were conducted in a total of 74 patients with mild or moderately severe hypertension treated with propranolol hydrochloride extended-release capsules 160 mg once daily or propranolol 160 mg given either once daily or in two 80 mg doses. Propranolol hydrochloride extended-release capsules were as effective as propranolol in controlling hypertension (pulse rate, systolic and diastolic blood pressure) in each of these trials.

For home management of patients taking propranolol, it is recommended to monitor:

• Blood pressure: to assess the effectiveness of propranolol in controlling hypertension
• Heart rate: to assess the effectiveness of propranolol in controlling pulse rate The usual maintenance dosage of propranolol for hypertension is 120 to 160 mg once daily. However, the dosage may vary depending on the individual patient's response to the medication. It is essential to follow the prescribed dosage and monitor blood pressure and heart rate regularly to ensure optimal management of hypertension while taking propranolol 2.

From the Research

Home Management of Blood Pressure or Heart Rate while Taking Propranolol

• Blood pressure response to propranolol is complex and cannot be explained by one mechanism alone, as it involves changes in cardiac output, heart rate, and total peripheral resistance (TPR) 3.
• With continued propranolol therapy, blood pressure is gradually reduced in responders, while cardiac output and rate remain low, indicating a readaptation of TPR to the new hemodynamic conditions 3.
• The effect of propranolol on heart rate is more pronounced at lower plasma concentrations, and standing heart rate decreases maximally at plasma propranolol concentrations greater than 25 ng/ml 4.
• Propranolol-induced changes in blood pressure values may predict the effectiveness of beta-blockade in preventing syncope during tilt testing, with a drug-induced reduction in systolic blood pressure of less than 5 mmHg identifying those who will benefit from beta-blocker therapy 5.
• Propranolol reduces both systolic and diastolic blood pressure and exercise heart rate in patients with essential hypertension, with similar maximum reductions in blood pressure achieved with different beta-adrenoceptor blocking drugs 6.
• Propranolol increases heart rate variability (HRV) and reduces heart rate and blood pressure, but does not affect pressure pain sensitivity or pain facilitatory or modulatory outcomes in healthy male subjects 7.

Monitoring Blood Pressure and Heart Rate

• Blood pressure and heart rate should be monitored regularly while taking propranolol to assess the effectiveness of the medication and adjust the dose as needed 3, 4, 6.
• Changes in blood pressure and heart rate can be used to predict the response to propranolol therapy and identify patients who may benefit from beta-blocker therapy 5.
• HRV can be increased by propranolol, which may have implications for pain modulation and autonomic nervous system activity 7.