Red Flags
- Acute decompensated HF on a beta-blocker — do NOT abruptly discontinue; titrate down only after stabilisation; rebound effects possible[1]
- Severe asthma or COPD with bronchospasm on a non-cardioselective beta-blocker — switch to cardioselective (bisoprolol, nebivolol) or non-beta-blocker class[1]
- Symptomatic bradycardia (HR <50 with dizziness/syncope) on beta-blocker — reduce dose or switch class[1]
- Diabetes with frequent hypoglycaemia on non-cardioselective beta-blocker — masks adrenergic warning; prefer cardioselective or alternative[1]
First-line treatment
Interventions
- Compelling indications take precedence[1]Beta-blocker is FIRST-LINE in: post-MI, HFrEF, angina, atrial fibrillation rate control, migraine prophylaxis, essential tremor, thyrotoxicosis. Otherwise positions as 4th-line in stepped therapy after CCB, ACE-i/ARB, and thiazide diuretic
- Avoid abrupt discontinuation[1]Taper over ≥2 weeks if discontinuing; abrupt withdrawal causes rebound hypertension, tachycardia, and (in CAD) ischaemia
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Bisoprolol[1] | Cardioselective beta-blocker | 2.5–10 mg PO once daily | — | Preferred when beta-blocker indicated; cardioselective minimises bronchospasm and metabolic effects |
| Metoprolol succinate (extended release)[1] | Cardioselective beta-blocker | 25–200 mg PO once daily | — | Alternative cardioselective option with strong HFrEF and post-MI evidence |
| Carvedilol[1] | Non-selective beta-blocker with alpha-1 blockade | 3.125–25 mg PO BD | — | Preferred in HFrEF, post-MI, and hypertension with diabetes (favourable metabolic profile) |
| Nebivolol[1] | Cardioselective beta-blocker with NO-mediated vasodilation | 2.5–10 mg PO once daily | — | Favourable metabolic profile; option in elderly, sexual dysfunction concerns, or HF with preserved EF |
Bisoprolol[1]
Cardioselective beta-blocker
- Adult
- 2.5–10 mg PO once daily
- Paediatric
- —
Preferred when beta-blocker indicated; cardioselective minimises bronchospasm and metabolic effects
Metoprolol succinate (extended release)[1]
Cardioselective beta-blocker
- Adult
- 25–200 mg PO once daily
- Paediatric
- —
Alternative cardioselective option with strong HFrEF and post-MI evidence
Carvedilol[1]
Non-selective beta-blocker with alpha-1 blockade
- Adult
- 3.125–25 mg PO BD
- Paediatric
- —
Preferred in HFrEF, post-MI, and hypertension with diabetes (favourable metabolic profile)
Nebivolol[1]
Cardioselective beta-blocker with NO-mediated vasodilation
- Adult
- 2.5–10 mg PO once daily
- Paediatric
- —
Favourable metabolic profile; option in elderly, sexual dysfunction concerns, or HF with preserved EF
Safety-net
- Do not stop beta-blocker abruptly even if you feel well — can trigger rebound high BP and chest pain[1]
- If you develop wheezing, severe fatigue, or feel your heart rate slow significantly — contact your clinician for dose review[1]
- If you have diabetes, monitor blood glucose more frequently after starting a beta-blocker — they can mask hypoglycaemia warning signs[1]
Referral criteria
- Symptomatic bradycardia or new heart block on beta-blockerCardiology for medication review and assessment for pacing[1]
- Resistant hypertension uncontrolled on triple therapy plus beta-blockerHypertension clinic for secondary cause workup[1]
- Severe asthma or COPD with bronchospasm on beta-blockerRespiratory and cardiology for class switch decision[1]
Clinical summary
Position on the contemporary role of beta-blockers in hypertension — first-line in compelling indications, fourth-line in uncomplicated hypertension.