What are beta-blockers?
Beta-blockers are a class of medications used to treat high blood pressure and heart failure. They are also given to women who have had a heart attack to prevent future heart problems. Beta-blockers slow the heart rate and decrease the strength of each heartbeat. This lowers your blood pressure and lessens the stress on your heart, slowing the progression of heart failure and improving survival.
|Generic Names:||Carvedilol / Metoprolol / Atenolol / Bisprolol / Propranolol / Timolol|
|Brand Names:||Coreg / Lopressor, Toprol XL / Tenormin / Zebeta / Inderal / Blocadren|
|How it is given:||Oral (tablet or capsule), intravenous (IV)|
|What it is used for:||
|You should not be treated with it if:||
|Pregnancy/nursing:||Discuss the risks and benefits of this medication with your doctor if you are planning to become pregnant. Pregnant women should not take atenolol because it can harm the fetus. The safety of the other beta-blockers during pregnancy is not known. Women who are nursing should only take beta-blocksers if the potential benefit clearly outweights the risks to the baby – discuss these with your doctor.1|
What are they used for?
Beta-blockers are one of the first medications given to a woman with systolic heart failure, even if she has not started having heart failure symptoms yet.2 In women with heart failure, beta-blockers relieve heart failure symptoms, improve your ability to perform basic daily tasks, and slow the progression of the disease. Women who are treated with beta-blockers require fewer hospital stays and live longer.
Who should receive beta-blockers to prevent or treat heart failure?
Women who have been diagnosed with heart failure, whether or not they have started having symptoms, benefit from treatment with beta-blockers to slow the progression of the disease and improve survival.2 In women who are at high risk of developing heart failure, beta-blockers can be used to help control high blood pressure and delay the onset of heart failure.
In women with systolic heart failure who do not yet have heart failure symptoms, treatment with beta-blockers results in improved heart function (as measured by ejection fraction) and improved survival.3 Beta-blockers also slow down the changes that occur in the heart during heart failure.4-6 By improving the heart's function and slowing down the heart's structural changes, beta-blockers delay the progression of heart failure and the onset of symptoms.
For women with blood pumping problems (systolic heart failure) who already have symptoms of heart failure, beta-blockers improve the heart's pumping ability and relieve heart failure symptoms, maing it easier to perform basic physical tasks.5-14 They also reduce hospital stays, and improve survival.15-18 A trial of 3991 patients (23% were women) with mild to severe heart failure found that adding a beta-blockers to standard heart failure treatment increased one-year survival by 34%.19 While women appeared to benefit to the same degree as men, the number of women in the study was too small to be certain.
The benefits of beta-blocker therapy in patients with diastolic heart failure (blood filling problems) are not as well defined. Beta-blockers can be used in women with diastolic heart failure to decrease blood pressure and may help to relieve heart failure symptoms.2 By slowing down your heart rate, beta-blockers give your heart more time to fill with blood. Lowering blood pressure may also help to relieve ventricular hypertrophy, thickening of the pumping chamber walls that happens in some women with blood filling problems.
Who should NOT receive beta-blockers?
Women with heart failure symptoms that change suddenly, requiring hospitalization or intravenous medications, should not start beta-blockers because it can make symptoms worse.20 Beta-blockers should be started carefully and slowly if you have severe lung disease or asthma, disease in the blood vessels of your legs (peripheral vascular disease), a slow heart rate (less than 60 beats per minute), low blood pressure, or if your heart has difficulty transmitting electrical signals (called heart block).20
Talk to your doctor about the risks and benefits of these medications if you are pregnant, nursing, or planning to become pregnant. Pregnant women should not take atenolol because it can harm the fetus, and the safety of the other beta-blockers during pregnancy is not known. Women who are nursing should not take beta-blockers; if the treatment is essential, then nursing should be discontinued.
How do beta-blockers work?
In heart failure, your heart has difficulty pumping enough blood to the rest of your body. As a result, your body's nervous system sends signals to your heart to pump harder and faster in an attempt to get more blood to your vital organs. In the short term, this adjustment works. In the long term, the overworked heart muscle gradually suffers damage, and will eventually no longer be able to meet the body's demands.
Beta-blockers prevent or slow this long-term damage by blocking the signals that tell your heart to speed up, effectively slowing your heart rate and decreasing the strength of the heart muscle's contractions.4,5 Because blood is being pushed through the vessels with less force, the medication also lowers your blood pressure.
Do beta-blockers work as well in women as in men?
Yes. Although women typically make up only 20% to 30% of subjects in the major trials, when data from many studies is combined researchers generally find that women benefit from treatment with beta-blockers.19,21-23 Among 898 women in one trial, women taking beta blockers had 42% fewer stays in the hospital for heart failure and 21% fewer deaths or hospitalizations compared to women taking placebos.21 When data from five of the largest studies of beta-blocker studies were combined, women and men had similar survival improvements when they took beta-blockers.24 Studies have also shown that beta blockers improve the heart's pumping ability in women.22
Are women missing out on beta-blocker therapy?
Despite studies demonstrating that women with heart failure benefit from beta-blocker therapy, several studies have found that women are slightly less likely to be prescribed beta-blockers compared with men.25-29 For example, one large study looked at the medical records of 105,388 patients and found that significantly fewer women were prescribed beta-blockers compared to men (55% vs. 58%). The reason for this modest gender difference in treatment is not clear.
Are beta-blockers as effective in African-Americans with heart failure?
In most cases, beta-blockers are just as effective in African Americans as in whites. However, race may affect the benefits received from specific types of beta-blockers. A report that combined data looking at a specific beta-blocker called carvedilol found that both blacks and non-black patients had the same benefit from beta-blocker use. However, unequal benefits were found in a trial with 2708 patients with moderate to severe heart failure (NYHA class III or IV) that looked specifically at bucindolol, another beta-blocker medication. Although deaths from cardiac problems were less common overall in the group of patients taking the beta-blocker, African-American patients did not benefit from this specific drug.13,30,31 Although different beta-blockers work in slightly different ways, it is not well understood why a patients of a certain race would respond better to one beta-blocker than another.
What are the side effects of beta-blockers?
Beta-blockers are usually well-tolerated medications. In fact, studies have found that patients were no more likely to stop taking beta-blockers because of side effects than they were to stop taking sugar pills.30,32 However, many experience fatigue that improves with time, and patients with a history of depression can become more depressed while taking beta-blockers.
Beta-blockers lower your heart rate, but most women do not notice this change during normal activities. You may feel less able to perform strenuous activities that would normally raise your heart rate, such as running, and become tired more easily when exercising. Dizziness is a relatively common side effect that may also be caused by a slow heart rate or by low blood pressure. However, this is rarely severe enough to require stopping treatment.33
In the past, beta-blockers were usually not given to patients with peripheral vascular disease because they could cause symptoms of the disease to get worse, such as cold hands and geet and pain in the legs after exercise. However, recent studies indicate that for most women with peripheral vascular disease, beta-blockers do not significantly affect walking capacity, leg pain symptoms, or skin circulation, and they have the benefit of improving survival.33-35
In some women with asthma or chronic obstructive lung disease, certain beta blockers (metoprolol, bispoprol) can worsen breathing problems.20 However, most patients with lung disease do not have airways that are sensitive enough to be affected by other beta-blockers, and studies have found that in general patients with lung disease tolerate beta-blockers as well as patients without lung disease.36,37
If I cannot take a beta-blocker, what are some alternatives?
There are several different types of beta-blockers that work in slightly different ways. If you are experiencing side effects, switching to a different type of beta-blocker often resolves the problem. Depending on why you are unable to take a beta-blocker, your doctor may want to decrease the dosage of your beta-blocker or try switching you to a different beta-blocker medication before completely stopping beta-blocker treatment.
My doctor has prescribed a beta-blocker. What should I watch out for?
While taking a beta-blocker, it is important to closely follow the doses prescribed to you. Beta-blockers decrease your heartbeat's strength, so your heart failure symptoms may get worse when first starting the drug.38,39 To avoid this, your doctor may start you on a lower dosage and then slowly increase the dosage with time if you are able to handle it.16 Let your doctor know if your symptoms get worse; she or he can lower your dose of beta-blockers or increase the dose of other medications to control symptoms. Do not stop your beta-blocker medication on your own because stopping suddenly can make your symptoms worse.
If you experience any other side effects while taking beta-blockers, such as dizziness, headaches, nausea, excess tiredness with exercise, or worsening of your symptoms of lung disease, asthma, or peripheral vascular disease, let your physician know. She or he may be able to minimize these side effects by adjusting your dose or switching you to a different type of beta-blocker.
Beta-blockers may interact poorly with some other types of medications called calcium-channel blockers (for example verapamil or diltiazem). If you are already taking any of this class of medication, be sure to talk to your doctor about any precautions you should take or symptoms you should mindful of.
- Hale TW. Medications and Mothers' Milk. 13 ed; 2008.
- Hunt SA. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. September 20, 2005 2005;46(6):e1-82.
- Colucci WS, Kolias TJ, Adams KF, et al. Metoprolol reverses left ventricular remodeling in patients with asymptomatic systolic dysfunction: the REversal of VEntricular Remodeling with Toprol-XL (REVERT) trial. Circulation. Jul 3 2007;116(1):49-56.
- Groenning BA, Nilsson JC, Sondergaard L, Fritz-Hansen T, Larsson HB, Hildebrandt PR. Antiremodeling effects on the left ventricle during beta-blockade with metoprolol in the treatment of chronic heart failure. J Am Coll Cardiol. Dec 2000;36(7):2072-2080.
- Doughty RN, Whalley GA, Gamble G, MacMahon S, Sharpe N. Left ventricular remodeling with carvedilol in patients with congestive heart failure due to ischemic heart disease. Australia-New Zealand Heart Failure Research Collaborative Group. J Am Coll Cardiol. Apr 1997;29(5):1060-1066.
- Bristow MR. Mechanism of action of beta-blocking agents in heart failure. Am J Cardiol. Dec 4 1997;80(11A):26L-40L.
- Gilbert EM, Anderson JL, Deitchman D, et al. Long-term beta-blocker vasodilator therapy improves cardiac function in idiopathic dilated cardiomyopathy: a double-blind, randomized study of bucindolol versus placebo. Am J Med. Mar 1990;88(3):223-229.
- Hole T, Froland G, Gullestad L, Offstad J, Skjaerpe T. Metoprolol CR/XL improves systolic and diastolic left ventricular function in patients with chronic heart failure. Echocardiography. Apr 2004;21(3):215-223.
- Andersson B, Hamm C, Persson S, et al. Improved exercise hemodynamic status in dilated cardiomyopathy after beta-adrenergic blockade treatment. J Am Coll Cardiol. May 1994;23(6):1397-1404.
- Hjalmarson A, Goldstein S, Fagerberg B, et al. Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group. JAMA. Mar 8 2000;283(10):1295-1302.
- Engelmeier RS, O'Connell JB, Walsh R, Rad N, Scanlon PJ, Gunnar RM. Improvement in symptoms and exercise tolerance by metoprolol in patients with dilated cardiomyopathy: a double-blind, randomized, placebo-controlled trial. Circulation. Sep 1985;72(3):536-546.
- Kukin ML, Kalman J, Charney RH, et al. Prospective, randomized comparison of effect of long-term treatment with metoprolol or carvedilol on symptoms, exercise, ejection fraction, and oxidative stress in heart failure. Circulation. May 25 1999;99(20):2645-2651.
- A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). CIBIS Investigators and Committees. Circulation. Oct 1994;90(4):1765-1773.
- Olsen SL, Gilbert EM, Renlund DG, Taylor DO, Yanowitz FD, Bristow MR. Carvedilol improves left ventricular function and symptoms in chronic heart failure: a double-blind randomized study. J Am Coll Cardiol. May 1995;25(6):1225-1231.
- Fowler MB, Vera-Llonch M, Oster G, et al. Influence of carvedilol on hospitalizations in heart failure: incidence, resource utilization and costs. U.S. Carvedilol Heart Failure Study Group. J Am Coll Cardiol. May 2001;37(6):1692-1699.
- Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med. May 23 1996;334(21):1349-1355.
- Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet. May 5 2001;357(9266):1385-1390.
- The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. Jan 2 1999;353(9146):9-13.
- Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. Jun 12 1999;353(9169):2001-2007.
- Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. Apr 14 2009;53(15):e1-e90.
- Ghali JK, Pina IL, Gottlieb SS, Deedwania PC, Wikstrand JC. Metoprolol CR/XL in female patients with heart failure: analysis of the experience in Metoprolol Extended-Release Randomized Intervention Trial in Heart Failure (MERIT-HF). Circulation. Apr 2 2002;105(13):1585-1591.
- Ghali JK, Krause-Steinrauf HJ, Adams KF, et al. Gender differences in advanced heart failure: insights from the BEST study. J Am Coll Cardiol. Dec 17 2003;42(12):2128-2134.
- Funck-Brentano C, Lancar R, Le Heuzey JY, Lardoux H, Soubrie C, Lechat P. Predictors of medical events in patients enrolled in the cardiac insufficiency bisoprolol study (CIBIS): a study of the interactions between beta-blocker therapy and occurrence of critical events using analysis of competitive risks. Am Heart J. Feb 2000;139(2 Pt 1):262-271.
- Shekelle PG, Rich MW, Morton SC, et al. Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials. J Am Coll Cardiol. May 7 2003;41(9):1529-1538.
- Galvao M, Kalman J, DeMarco T, et al. Gender differences in in-hospital management and outcomes in patients with decompensated heart failure: analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Card Fail. Mar 2006;12(2):100-107.
- Baumhakel M, Muller U, Bohm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail. Mar 2009;11(3):299-303.
- Lenzen MJ, Rosengren A, Scholte op Reimer WJ, et al. Management of patients with heart failure in clinical practice: differences between men and women. Heart. Mar 2008;94(3):e10.
- Mejhert M, Holmgren J, Wandell P, Persson H, Edner M. Diagnostic tests, treatment and follow-up in heart failure patients--is there a gender bias in the coherence to guidelines? Eur J Heart Fail. Dec 1999;1(4):407-410.
- Komajda M, Follath F, Swedberg K, et al. The EuroHeart Failure Survey programme--a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment. Eur Heart J. Mar 2003;24(5):464-474.
- Gottlieb SS, Fisher ML, Kjekshus J, et al. Tolerability of beta-blocker initiation and titration in the Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF). Circulation. Mar 12 2002;105(10):1182-1188.
- A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure. N Engl J Med. May 31 2001;344(22):1659-1667.
- Ko DT, Hebert PR, Coffey CS, et al. Adverse effects of beta-blocker therapy for patients with heart failure: a quantitative overview of randomized trials. Arch Intern Med. Jul 12 2004;164(13):1389-1394.
- Ubbink DT, Verhaar EE, Lie HK, Legemate DA. Effect of beta-blockers on peripheral skin microcirculation in hypertension and peripheral vascular disease. J Vasc Surg. Sep 2003;38(3):535-540.
- Feringa HH, van Waning VH, Bax JJ, et al. Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol. Mar 21 2006;47(6):1182-1187.
- Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med. May 24 2001;344(21):1608-1621.
- Salpeter S, Ormiston T, Salpeter E. Cardioselective beta-blockers for reversible airway disease. Cochrane Database Syst Rev. 2002(4):CD002992.
- Kotlyar E, Keogh AM, Macdonald PS, Arnold RH, McCaffrey DJ, Glanville AR. Tolerability of carvedilol in patients with heart failure and concomitant chronic obstructive pulmonary disease or asthma. J Heart Lung Transplant. Dec 2002;21(12):1290-1295.
- Miller RR, Olson HG, Amsterdam EA, Mason DT. Propranolol-withdrawal rebound phenomenon. Exacerbation of coronary events after abrupt cessation of antianginal therapy. N Engl J Med. Aug 28 1975;293(9):416-418.
- Psaty BM, Koepsell TD, Wagner EH, LoGerfo JP, Inui TS. The relative risk of incident coronary heart disease associated with recently stopping the use of beta-blockers. JAMA. Mar 23-30 1990;263(12):1653-1657.