Why was my patient started on a beta‑blocker despite a normal resting electrocardiogram and normal echocardiogram, and should I taper it to determine if it is masking an underlying condition?

Why Your Patient May Be on a Beta-Blocker Despite Normal Testing

Do not taper the beta-blocker without first identifying the original indication—abrupt discontinuation can precipitate serious cardiac events including angina exacerbation, myocardial infarction, and ventricular arrhythmias, particularly in patients with underlying coronary artery disease. 1

Critical Safety Considerations

Beta-blockers should never be abruptly discontinued, especially in patients with coronary artery disease, even if that diagnosis is unrecognized. The FDA label for metoprolol explicitly warns that severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias have been reported following abrupt discontinuation. 1 When discontinuation is necessary, the dosage must be gradually reduced over 1-2 weeks with careful patient monitoring. 1

The "Masking" Concern is Misguided

Your concern about the beta-blocker "masking something" reflects a common misconception about these medications. 2 A normal resting EKG and echocardiogram do not exclude valid indications for beta-blocker therapy. Many evidence-based indications for beta-blockers are not detectable on these static tests.

Common Indications Not Visible on Resting EKG or Echo

Arrhythmia Management

• Atrial fibrillation or other atrial arrhythmias are the most common reason physicians initiate beta-blockers, including in patients without structural heart disease. 3, 4
• Supraventricular tachycardia (SVT) and ventricular arrhythmias are established indications where beta-blockers serve as first-line therapy. 4
• Palpitations or symptomatic tachycardia may have prompted beta-blocker initiation even if the resting EKG appears normal. 5

Ischemic Heart Disease

• Stable angina is a Class I indication for beta-blockers as first-line anti-ischemic therapy, particularly when accompanied by high heart rate or hypertension. 6
• Post-myocardial infarction patients require beta-blockers regardless of current EKG or echo findings. 5
• Coronary artery disease may be present despite normal resting studies—stress testing or coronary angiography would be needed to exclude ischemia. 1

Hypertension

• Beta-blockers may have been prescribed for blood pressure control, though they are no longer considered first-line for uncomplicated hypertension. 2
• Combination therapy with hypertension and tachycardia is a reasonable indication. 6

Heart Failure

• Heart failure with reduced ejection fraction (HFrEF) is a strong indication even if the patient is currently compensated with normal exam findings. 5
• Beta-blockers should be started early in HFrEF and continued indefinitely as they reduce mortality and prevent disease progression. 5

Other Cardiac Conditions

• Hypertrophic cardiomyopathy (HCM) requires beta-blockers to reduce left ventricular outflow tract obstruction, which may only be evident during exercise or stress. 5
• Long QT syndrome and other inherited arrhythmia syndromes use beta-blockers as prophylaxis. 4
• Microvascular angina responds to beta-blocker therapy combined with RAS blockers and statins. 6

The Appropriate Investigative Approach

Review the Medical Record Thoroughly

• Check the original prescription note to identify the documented indication. 3
• Review ambulatory monitoring results (Holter, event monitor, or wearable device data) that may have captured arrhythmias not present on resting EKG. 5
• Look for stress test results that may have shown ischemia or exercise-induced arrhythmias. 5
• Examine the medication list for clues—presence of anticoagulation suggests atrial fibrillation; presence of nitrates suggests angina. 6

Assess for Symptoms That Warranted Beta-Blocker Initiation

• Syncope or near-syncope are Class I indications for EKG evaluation and may have prompted beta-blocker therapy. 5
• Palpitations are a common indication for beta-blocker use. 5, 4
• Chest pain or angina may have been present initially even if currently controlled. 5
• Dyspnea or exercise intolerance could indicate heart failure or ischemia. 5

Consider Consultation Before Discontinuation

• Contact the prescribing physician to clarify the indication if documentation is unclear. 3
• Cardiology consultation is appropriate if you cannot identify a clear indication and are considering discontinuation. 3

When Beta-Blocker Discontinuation Might Be Appropriate

Only consider tapering if you have definitively ruled out all evidence-based indications and the patient is experiencing significant adverse effects. 7

Common Adverse Effects That May Warrant Dose Reduction

• Fatigue is common and may resolve spontaneously within weeks, but severe cases warrant dose reduction rather than abrupt discontinuation. 7
• Fluid retention detected by weight gain should be managed with diuretic adjustment while continuing beta-blocker. 7
• Bradycardia (heart rate <50-60 bpm) with symptoms like dizziness may require dose reduction. 7, 1
• Hypotension particularly with alpha-blocking agents like carvedilol. 7

The Gradual Taper Protocol

If discontinuation is truly necessary after ruling out contraindications:

• Reduce dose by 25-50% every 1-2 weeks rather than stopping abruptly. 1
• Monitor closely for return of symptoms including chest pain, palpitations, or dyspnea. 1
• Check heart rate and blood pressure at each dose reduction. 7
• Be prepared to reinstate therapy if angina worsens or acute coronary insufficiency develops. 1

Common Pitfall to Avoid

The most dangerous assumption is that "normal tests mean no indication." 3 A significant proportion of physicians prescribe beta-blockers without documented evidence-based indications, but conversely, many valid indications are not visible on resting studies. 3 The fact that 76.6% of physicians report reluctance to deprescribe beta-blockers initiated by another clinician—citing concern about interfering with another physician's treatment plan—suggests the original prescriber likely had a specific indication in mind. 3

Your safest course of action is to identify the original indication before considering any medication changes, as abrupt withdrawal can precipitate life-threatening cardiac events. 1