If you spend any time talking about health with older Americans, the topic of beta blockers will inevitably come up. But what are they, and how dangerous is it to take them? And why do so many people seem to need them? “The number one use of beta blockers in the country is to treat hypertension, that’s because of the sheer numbers of people with hypertension,” says Raymond Bietry, MD, a specialist in advanced heart failure at Ascension Seton Medical Center in Austin, Texas. “But their chief benefit is for those with heart failure.”
Beta blockers are considered a “first line of defense” for patients with a weak heart, with coronary artery disease, or who’ve experienced a heart attack. But they’re not used alone as a treatment for high blood pressure. In fact, a study published in the journal BMC Geriatrics found that older people taking beta blockers for high blood pressure were more likely to experience heart attack, stroke, or death than those taking other hypertension medications.
Beta blockers are usually given to patients following a heart attack, but research suggests that they are only required after a heart attack when the event is accompanied by heart failure, where the heart is permanently damaged. Many heart attacks do not involve heart failure, yet many of those patients are still prescribed beta blockers.
In a study published in the Journal of the American College of Cardiology, researchers focused on data regarding 179,000 patients who suffered a heart attack without heart failure. After a year following the heart attack, there was no difference in the death rates between those prescribed a beta blocker and those who were not.
The study questions whether beta blockers should be prescribed at all to those who have had a heart attack but did not suffer heart failure. “This study suggests that there may be no mortality advantage associated with the prescription of beta-blockers for patients with heart attack and no heart failure,” Chris Gale, MD, a cardiologist at the University of Leeds (UK), who worked on the study, said in a statement. If there is only a benefit to a specific group of people then anyone outside of that group who is prescribed the drug is risking side effects and interactions with other medicines for no benefit.
Still, beta blockers are among the most commonly prescribed medications in the US — tens of millions take them after they’ve had a heart attack, or after being diagnosed with heart failure or coronary artery disease. Beta blockers are also frequently prescribed to help control and better manage irregular heart rhythms and non-cardiovascular conditions, including migraines and glaucoma.
While most people can safely tolerate beta blockers, there are side effects ranging from constipation to shortness of breath that need to be considered and thoroughly understood, says Andrew Freeman, MD, the director of clinical cardiology at National Jewish Health in Denver, who also serves on the Patient Centered Care Committee for the American College of Cardiology. Have a frank discussion with your doctor, he urges, discussing the benefits you might gain, but also the side effects you might experience, and what you can do about them.
How Beta Blockers Work
“You’ve heard of the body’s fight-or-flight response?” says Dr. Bietry. “That response gets switched on when your body is under some form of stress.” Beta adrenergic receptors that exist in a lot of different tissue, including cardiac tissue, are activated. Adrenaline (also known as the hormone epinephrine) is released. When that happens over and over, your heart gets damaged, he says, even changing in size and shape. Beta blockers prevent the hormones released during the stress response from causing additional damage to your heart.
There are more than a dozen beta blockers that treat a number of conditions, but essentially they all work in a similar fashion: They slow down heart rate and allow the heart to beat with less force by blocking the effects of adrenaline and other neurohormones. They also work to open up blood vessels, improving blood flow. Because there are multiple beta adrenergic receptors found in the heart, lungs, other organs, and in the smooth muscle that lines blood vessels, doctors select beta blockers according to which adrenergic receptor(s) a particular drug interrupts.
That’s why, for example, a patient with chronic stable angina or another who recently had a heart attack might be prescribed carvedilol, while another patient who is experiencing frequent migraines might be put on propranolol, and a glaucoma patient will be prescribed timolol drops. When selecting beta blockers doctors also consider the patient’s medical history and any other medications they’re currently taking.
If you have high blood pressure, explains Dr. Bietry, hypertensive meds other than beta blockers are a smarter, more benign choice. Diuretics (water pills) and lifestyle changes (such as losing a modest amount of weight, exercising, managing stress, and quitting smoking) are often the first steps for lowering blood pressure. (See MedShadow’s Ways to Lower High Blood Pressure Without Relying on Drugs.) Beta blockers are typically introduced to the treatment regimen if diuretics and/or lifestyle changes alone aren’t effective. Nearly all beta blockers have been FDA-approved to treat high blood pressure. Individual circumstances ultimately guide the selection of treatment options.
Dr. Freeman adds: “A lot of patients think of beta blockers as blood pressure medications — after all, that’s what it says on the package insert when they pick it up from the pharmacy. But the key use of beta blockers is to treat coronary disease, improve heart function and prevent heart failure.”
Potential Side Effects
Beta blockers, like all medications, come with a host of possible side effects, some more common than others. (See MedShadow’s Side Effects of 5 Drugs Seniors Commonly Take.) All side effects should be addressed promptly. Common side effects include:
- Cold hands and feet
- Weight gain
Less common or rare side effects include:
- Constipation or diarrhea
- Erectile dysfunction or loss of sex drive
- Muscle and joint pain
- Shortness of breath or difficulty breathing (bronchial spasm)
- Trouble sleeping
“There’s a risk-benefit analysis that must be done on a person-by-person basis to determine if the side effect is debilitating enough that it outweighs the benefit that it’s having for your heart,” says Dr. Bietry, who adds that in his practice fatigue is the most common complaint he hears about. That loss of energy usually resolves itself in the first week or two, he says, but if it lingers — or if it interferes with your ability to get regular physical exercise — doctors typically try a different dose or perhaps a different beta blocker.
Dizziness, problems with balance and gait, and postural hypotension (blood pressure drops when you stand up from sitting or sit up from lying down, also known as orthostatic hypotension) are of particular concern among older patients. Falls among elderly patients can have catastrophic consequences — traumatic brain injury, bone fractures (particularly of the hip) and dislocated joints that severely limit mobility, even death. In a study of nearly 5,000 older people with hypertension and multiple other conditions, researchers determined that those taking any antihypertensive drugs were at increased risk of a serious fall resulting in injury. Those who had fallen in the previous year were more than twice as likely to fall during the study period. No particular antihypertensive medication (including beta blockers, diuretics, calcium channel blockers, renin-angiotensin system blockers, and others) was more likely to be associated with falls.
However, for some people, getting high blood pressure under control with antihypertensive medication may help protect against falling. In a study published in the Journal of the American Geriatrics Society, older people with uncontrolled hypertension and postural hypotension were 2 ½ times more likely to fall within a year. Those whose high blood pressure was controlled, whether or not they experienced postural hypotension, were not at greater risk of falling. Another study, published in the journal Hypertension, found that older people with high blood pressure who took calcium channel blockers were significantly less likely to fall, possibly due to an increase in blood flow to the brain.
In any case, beta blockers are not recommended as first-line treatment of high blood pressure. Research has shown that the benefits of beta blockers are inferior to those of other antihypertensive drugs. Ther
efore it’s not recommended they take these drugs for the sole purpose of lowering blood pressure.
Some people experience depression after going on a beta blocker (See MedShadow’s 5 Drug Classes That May Cause Depression), and that is one side effect that’
s more complex. “It’s tough to figure out the interaction between the medication and depression,” says Dr. Bietry, “but I’ve seen patients who’ve had a significant
improvement in their mental health with the discontinuation of a beta blocker.” This is an area he says needs more research.
Side effects, drug interactions and the other conditions a person has all play a role in choosing the best beta blocker for each individual. (See MedShadow’s Heart Drugs Can Interact with Common Meds.) For example, patients with asthma or COPD (chronic obstructive pulmonary disease) are often advised to only take cardioselective beta
blockers — those that primarily block beta receptors on the heart. These include metoprolol, atenolol, bisoprolol, and others. These have been shown to be less irritating and often well-tolerated by those with non-severe asthma or COPD.
A word of caution: If you’re currently taking a beta blocker and experience a side effect, do not stop taking it without the guidance of your doctor. Serious cardiac complications could arise. The same goes for changing the dose; if you feel a lower dose might be more appropriate for you, raise your concerns with your doctor.
Common Beta Blockers
Different beta blockers are prescribed for different conditions and/or for specific factors. Most are used along with a diuretic for hypertension. Following are common beta blockers for the heart:
- Acebutolol: commonly prescribed for certain heart rhythm problems and angina
- Atenolol: often prescribed after a heart attack and to prevent angina
- Betaxolol pills: used as a second drug for high blood pressure
- Bisoprolol: sometimes prescribed for heart failure
- Carvedilol: most commonly prescribed for mild or severe heart failure
- Labetalol: an injection form is used to treat severe high blood pressure (hypertensive emergency); a pill form is sometimes prescribed as a second drug for high blood pressure
- Metoprolol: metoprolol tartrate is often prescribed for angina, after a heart attack, or as a second drug for high blood pressure; metoprolol succinate (extended release) for heart failure and angina
- Nadolol: often prescribed as a second drug for high blood pressure, also for angina
- Nebivolol: most commonly prescribed as a second drug for high blood pressure
- Pindolol: primarily used as a second drug for high blood pressure; sometimes used to prevent angina and heart attacks
- Propranolol: commonly prescribed for angina, arrhythmia, after a heart attack, or as a second drug for high blood pressure
- Sotalol: primarily used to treat irregular heartbeats
- Timolol pills: sometimes used after a heart attack and as a second drug to treat high blood pressure
Beta blocker drops commonly used for glaucoma:
- Timolol solution
- Betaxolol solution
Why Non-Cardiac Reasons Beta Blockers are Prescribed
- To treat glaucoma: Here, a topical beta blocker (in the form of an eye drop) is given to reduce the amount of fluid in the interior of the eye (known as aqueous humor). It’s believed that increased fluid pressure in the eye causes the damage, which can lead to blindness. Some of the eye-specific side effects the drops may cause include pain, stinging, or redness in the eyes. People using beta blocker drops are also at risk for some of the same side effects that the pills trigger, including fatigue, shortness of breath or reduced libido.(See MedShadow’s Glaucoma: 3 Ways to Treat a Sneaky Disease.)
- To prevent migraines: The beta blockers metoprolol, propranolol and timolol have been shown to help prevent migraines and/or reduce the frequency and severity of migraines. Two others, atenolol and nadolol, have also shown some benefit in preventing migraines. Fatigue is a main concern, and your doctor may need to try different doses to bring relief with minimal side effects.
- To ease performance anxiety: Going back to Dr. Bietry’s “fight-or-flight” response explanation, beta blockers interfere with the stress response that stimulates the heart to beat faster. Propranolol and atenolol, in particular, have been shown to be helpful in relieving the symptoms of performance anxiety. In this instance they’re typically given for a specific period of time before a major event. But doctors caution that the first time to try a beta blocker is not the day of a career-breaking presentation.
- Other areas of research: Because of the way beta blockers interact with stress hormones, which are believed to stimulate cancer cells, researchers are exploring ways beta blockers may help slow or minimize the spread of breast cancer and other cancers, and improve the body’s response to immunotherapy and other cancer treatments in people with advanced melanoma, multiple myeloma, and others. The beta blocker celiprolol is under investigation for treating vascular Ehlers-Danlos syndrome, a genetic condition that can cause arteries to be fragile and easily rupture, leading to premature death.There’s also ongoing research that explores what role, if any, beta blockers might play in the treatment of post traumatic stress disorder.
Until 2017 hypertension was defined as a systolic (top number) blood pressure reading of 140 mm Hg or higher, or a diastolic blood pressure of 80 mm Hg or higher. So anything higher than 140/80 was considered hypertension. But after decades of research on management of hypertension, and particularly after evidence from the landmark government study called SPRINT (Systolic Blood Pressure Intervention Trial), experts from the American College of Cardiology (ACC) and the American Heart Association (AHA) issued new guidelines. SPRINT revealed that for people age 50 and older with high blood pressure, getting systolic blood pressure below 120 by using (on average) three blood pressure medications reduced the rates of cardiovascular events (heart attack, heart failure, stroke) by 25% and the risk of death by 27%. In the new guidelines the ACC/AHA redefined hypertension as a systolic reading of 130 or higher, or a diastolic reading of 80 or higher.
The new blood pressure cut offs for hypertension would mean 31.3 million more Americans would be diagnosed with hypertension, and 11 million more Americans would need medication to lower their blood pressure, according to a study in JAMA Cardiology. These changes would be expected to result in 340,000 fewer major cardiovascular events and 156,000 fewer deaths. However, the number of medication side effects would also increase substantially. It’s estimated that this additional use of antihypertensives would lead to an additional 79,000 acute kidney injury or failure events, 62,000 cases of low blood pressure, 32,000 syncope (fainting due to low blood pressure) events, and 31,000 electrolyte abnormality events.
The Role Lifestyle Plays
Going back to the primary reason beta blockers are prescribed in the United States — cardiovascular health — Dr. Freeman emphasizes that lifestyle trumps everything.
Although it’s rare in the US for someone who’s had a heart attack or who suffers from dangerously high blood pressure to get off medications, including beta blockers, completely, it’s not impossible. He cited one 50-year-old male patient who’d suffered a pretty decent sized heart attack and, as Dr. Freeman puts it, “saw the light,” and made such significant lifestyle changes with diet and exercise that he needs just a tiny dose of a beta blocker.
The number-one way to reduce your risk of heart disease? Exercise. (Although if you are currently on a beta blocker, be cautious about your exercise intensity and check with your doctor before starting any new workout plan.) “I recommend 30 minutes a day during which it’s hard to talk,” Dr. Freeman says, adding that a mostly plant-based diet (less meat, especially red meat, and more vegetables, beans and legumes, etc.) is also key. (See MedShadow’s Exercise as Medicine.)
The mind-body connection is also important. “One of the things we use these drugs for ishypertension, and that means too much tension,” Dr. Freeman points out. Being in stressful situations raises your heart attack risk, so it’s smart to take a holistic approach to your health. You could seek out ways to either lower your stress or help you body handle it better.