• Beta-blockers are contraindicated in people with:
• A history of asthma or bronchospasm (beta-blockers can be used in people with chronic obstructive pulmonary disease, but caution should be used if disease is severe).
• Second- or third-degree heart block (in the absence of a permanent pacemaker).
• Sick sinus syndrome.
• Sinus bradycardia (heart rate less than 50 beats per minute at the start of treatment).
• Severe hypotension.
• Severe peripheral arterial disease (pain at rest and sometimes intermittent claudication) — the blood pressure-lowering properties of beta-blockers can exacerbate symptoms.
• Uncontrolled heart failure.
• Seek specialist advice before starting a beta-blocker in people with a current or recent exacerbation of heart failure.

In depth

• CKS recommends atenolol, bisoprolol, or metoprolol as first-choice beta-blockers for the management of angina.
• For people who have had a previous myocardial infarction, metoprolol (standard release), propranolol (standard release), timolol, or atenolol may be preferred.
• For more information, see the CKS topic on MI - secondary prevention.
• For people with angina and heart failure, bisoprolol, carvedilol, or nebivolol may be preferred.
• For more information, see the CKS topic on Heart failure - chronic.

In depth

• Titrate the dose of beta-blocker to the target dose (or maximum tolerated dose), according to the person's response and heart rate control (at rest and during exercise).
• Recommended target doses are:
• Atenolol 100 mg once a day or 50 mg twice a day (twice-daily dosing may provide better symptom control).
• Bisoprolol 10 mg once a day.
• Metoprolol 100 mg three times a day (standard-release) or 200 mg once a day (modified-release).

In depth

• Cold extremities, paraesthesiae, and numbness can occur, and beta-blockers can worsen symptoms in people with peripheral vascular disease — use a cardioselective beta-blocker (such as atenolol, bisoprolol, and metoprolol).
• Sleep disturbance or nightmares can occur — use a water-soluble beta-blocker (such as atenolol).
• Fatigue and sexual dysfunction can occur but do not usually necessitate stopping the beta-blocker.
• Ask people taking a beta-blocker whether they are having sexual problems.
• Warning signs of hypoglycaemia (such as tremor and tachycardia) can be masked by non-selective beta-blockers — use a cardioselective beta-blocker in people with diabetes.

In depth

• Verapamil and diltiazem
• The combination of a beta-blocker and verapamil must not be prescribed.
• The combination of a beta-blocker and diltiazem should only be prescribed on specialist advice.
• Class I antiarrhythmics (such as quinidine, disopyramide, flecainide, lidocaine)
• The combination of a beta-blocker and a class I antiarrhythmic is not recommended.
• Amiodarone
• The combination of a beta-blocker and amiodarone should be prescribed with caution — monitor pulse and blood pressure, and check for signs of worsening heart failure, as there is an increased risk of bradycardia, atrioventricular (AV) block, and myocardial depression. Amiodarone should not be initiated in primary care unless on specialist advice.
• Digoxin
• Concomitant administration of a beta-blocker and digoxin can reduce heart rate and prolong AV conduction time, increasing the risk of AV block and bradycardia — monitor pulse.
• Other drugs that reduce blood pressure
• An additive hypotensive effect may occur — monitor for signs of hypotension (such as dizziness, light-headedness, and confusion).

In depth