Beta blockers

Last updated: September 6, 2023

Summarytoggle arrow icon

Beta blockers are a group of drugs that inhibit the sympathetic activation of β-adrenergic receptors. Cardioselective blockers (e.g., atenolol, bisoprolol) primarily block β1 receptors in the heart, causing decreased heart rate, cardiac contractility, cardiac workload, and AVN conduction. Nonselective beta blockers (e.g., pindolol, propranolol) inhibit all β receptors and may cause bronchoconstriction, peripheral vasoconstriction, and metabolic imbalances (e.g., hypoglycemia and hyperglycemia, hypertriglyceridemia) in addition to cardiac effects. Cardioselective beta blockers have a lower side-effect profile and are preferred in the management of coronary heart disease, compensated heart failure, acute coronary syndrome, and certain types of arrhythmias. Propranolol, a nonselective beta blocker, is the first-line drug in the management of essential tremor, portal hypertension, migraine prophylaxis, and thyroid storm. Beta blockers are contraindicated in patients with symptomatic bradycardia, AV block, decompensated heart failure, and asthma. Initiation and cessation of beta-blocker therapy should always be gradual to avoid side effects or symptoms of withdrawal (e.g., rebound tachycardia, hypertension, acute cardiac death).

See also “Beta blocker poisoning.”

Overviewtoggle arrow icon

Characteristics of beta blockers
Type Agents Effects Side effects Indications
Cardioselective beta blockers (β1 selective) With intrinsic sympathomimetic activity (ISA)
  • Acebutolol
  • Celiprolol
Without ISA
  • Atenolol [4]
  • Metoprolol
  • Esmolol
  • Bisoprolol
  • Betaxolol
  • Bevantolol
  • Nebivolol
Nonselective beta blockers1, β2, and β3receptors) With ISA
  • Pindolol
  • Penbutolol
  • Oxprenolol
Without ISA
  • Propranolol
  • Nadolol
  • Sotalol
  • Timolol
  • Tertalol
With additional α-blocking action
  • Labetalol
  • Bucindolol
  • Carvedilol [5]

With the exception of nebivolol, all cardioselective beta blockers begin with the letters A to M (B1 = first half of the alphabet). Except for beta blockers with alpha-blocking action (labetalol, bucindolol, carvedilol), all noncardioselective beta blockers begin with the letters N to Z (B2 = second half of the alphabet).


Pharmacodynamicstoggle arrow icon

Beta blockers competitively bind to and block β-adrenergic receptors, thereby inhibiting sympathetic (adrenergic and/or noradrenergic) stimulation of β receptors. See “The sympathetic vs. parasympathetic nervous system” for details regarding the effects of β-adrenergic stimulation.

Effects of β-adrenergic blockade

Overview of β-adrenergic blockade [3]
Types of β receptors Main site of action Effects of β-adrenergic blockade
  • Anti-ischemic effect: β1 blockade → heart rate and ↓ cardiac contractility ↓ blood pressure (BP) and ↓ oxygen consumption by the heart anti-ischemic effect
  • Antiarrhythmic effect: β1 blockade → AVN conduction, AVN refractory time, and heart rate anti-arrhythmic effect
  • Anti-remodeling effect

Beta blockers competitively inhibit adrenergic substances (e.g., adrenaline, noradrenaline) at β receptors.
A rule to remember the main effector organs for β receptors: There is 1 heart (β1 blockers act on the heart) and 2 lungs (β2 blockers affect bronchial smooth muscles).

Intrinsic sympathomimetic activity (ISA) [6][8]

Pharmacokineticstoggle arrow icon

Pharmacokinetics of beta blockers
Lipophilic agents Hydrophilic agents Mixed
  • Undergo hepatic clearance
  • Penetrate the blood-brain-barrier → central/neurological adverse effects (esp. nightmares and insomnia)
  • Long-acting: most require a single dose per day


Adverse effectstoggle arrow icon

See “Beta blocker poisoning” for features of overdose and their management.


Beta blockers adverse effects
Type of beta blockers Organ system Effects

Nonselective beta blockers and cardioselective beta blockers

(β1-receptor and β2-receptor blockade)


CNS [17][18]


Nonselective beta blockers

(β2-receptor blockade)

Peripheral vasculature

Beta blockers should be introduced gradually with slow increases in dosage and slowly tapered off when no longer needed.

A number of beta blockers (e.g., metoprolol, carvedilol) are metabolized by CYP2D6. Genetic polymorphisms of CYP2D6 (e.g., ultra-rapid metabolization, poor metabolization) can influence adverse effects and tolerated doses. [24]

Beta-blocker withdrawal

Caused by the sudden termination of beta blockers

We list the most important adverse effects. The selection is not exhaustive.

Indicationstoggle arrow icon

Cardiovascular indications

Specific indications for propranolol


Contraindicationstoggle arrow icon

Contraindications to beta blockers
Absolute contraindications Relative contraindications

We list the most important contraindications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Hilas O, Ezzo D. Nebivolol (bystolic), a novel Beta blocker for hypertension.. P & T : a peer-reviewed journal for formulary management. 2009; 34 (4): p.188-92.
  2. Nebivolol (bystolic), a novel Beta blocker for hypertension. Hilas O, Ezzo D. P T. 2009; 34 (4): p.188-192.
  3. Gorre, Vanderckhove. Beta-blockers: focus on mechanism of action. Which beta-blocker, when and why?. Acta Cardiologica. 2010; 65 (5): p.565-570.doi: 10.2143/AC.65.5.2056244 . | Open in Read by QxMD
  4. Craig D. McClain, Michael L. McManus. A Practice of Anesthesia for Infants and Children. Elsevier Health Sciences ; 2009: p. 159-175
  5. Book. Carvedilol: A Nonselective Beta-blocking Agent With Antioxidant Properties. Congestive Heart Failure. ; 8 (3): p.173-7.
  6. Frishman WH. Clinical significance of beta 1-selectivity and intrinsic sympathomimetic activity in a beta-adrenergic blocking drug. Am J Cardiol. 1987; 59 (13): p.33F-37F.
  7. Gleiter CH, Deckert J. Adverse CNS-effects of beta-adrenoceptor blockers. Pharmacopsychiatry. 1996; 29 (6): p.201-211.doi: 10.1055/s-2007-979572 . | Open in Read by QxMD
  8. Jailon. Relevance of intrinsic sympathomimetic activity for beta blockers. 66. 1990; 9: p.21C-23C.
  9. Man in 't Veld. Haemodynamic consequences of intrinsic sympathomimetic activity and cardioselectivity in beta-blocker therapy for hypertension. European Heart Journal. 1986: p.D:31-41.
  10. Lehtonen. Effect of beta blockers on blood lipid profile. American Heart Journal. 1985.
  11. Wax MB, Molinoff PB. Distribution and properties of beta-adrenergic receptors in human iris-ciliary body. Invest Ophthalmol Vis Sci. 1987; 28 (3): p.420-430.
  12. Sambhara D, Aref AA. Glaucoma management: relative value and place in therapy of available drug treatments. Ther Adv Chronic Dis. 2013; 5 (1): p.30-43.doi: 10.1177/2040622313511286 . | Open in Read by QxMD
  13. Barrueto F Jr, Traub SJ, Grayzel J. Beta Blocker Poisoning. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: April 29, 2016. Accessed: April 7, 2017.
  14. Acebutolol. Updated: June 20, 2019. Accessed: September 20, 2019.
  15. Kamaruzzaman S, Watt H, Carson C, Ebrahim S. The association between orthostatic hypotension and medication use in the British Women's Heart and Health Study. Age Ageing. 2009; 39 (1): p.51-56.doi: 10.1093/ageing/afp192 . | Open in Read by QxMD
  16. Milazzo V, Di Stefano C, Servo S, et al. Drugs and Orthostatic Hypotension: Evidence from Literature. J Hypertens. 2012; 1: p.104.doi: 10.4172/2167-1095.1000104 . | Open in Read by QxMD
  17. Koella WP. CNS-related (side-)effects of β-Blockers with special reference to mechanisms of action. Eur J Clin Pharmacol . 1985; 28 (Suppl 1): p.55.doi: 10.1007/BF00543711 . | Open in Read by QxMD
  18. Mcainsh J, Cruickshank JM. Beta-blockers and central nervous system side effects. Pharmacol Ther. 1990; 46 (2): p.163-197.doi: 10.1016/0163-7258(90)90092-G . | Open in Read by QxMD
  19. Kim GK, Del rosso JQ. Drug-provoked psoriasis: is it drug induced or drug aggravated?: understanding pathophysiology and clinical relevance. J Clin Aesthet Dermatol. 2010; 3 (1): p.32-38.
  20. Silvestri et al.. Report of erectile dysfunction after therapy with beta-blockers is related to patient knowledge of side effects and is reversed by placebo. European Heart Journal. 2003: p.1928-1932.doi: 10.1016/j.ehj.2003.08.016 . | Open in Read by QxMD
  21. Charles Khouri, Sophie Blaise, Patrick Carpentier, Céline Villier, Jean-Luc Cracowski, Matthieu Roustit. Drug-induced Raynaud's phenomenon: beyond β-adrenoceptor blockers. Br J Clin Pharmacol. 2016; 82 (1): p.6-16.doi: 10.1111/bcp.12912 . | Open in Read by QxMD
  22. Fogari R, Zoppi A, Corradi L, Preti P, Mugellini A, Lusardi P. Beta-blocker effects on plasma lipids during prolonged treatment of hypertensive patients with hypercholesterolemia. J Cardiovasc Pharmacol. 1999; 33 (4): p.534-539.
  23. Vue MH, Setter SM. Drug-Induced Glucose Alterations Part 1: Drug-Induced Hypoglycemia. Diabetes Spectrum. 2011; 24 (3): p.171-177.doi: 10.2337/diaspect.24.3.171 . | Open in Read by QxMD
  24. Luzum JA, Sweet KM, Binkley PF, et al. CYP2D6 Genetic Variation and Beta-Blocker Maintenance Dose in Patients with Heart Failure. Pharm Res. 2017; 34 (8): p.1615-1625.doi: 10.1007/s11095-017-2104-8 . | Open in Read by QxMD
  25. Kaplan NM. Withdrawal syndromes with antihypertensive therapy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: March 21, 2016. Accessed: April 7, 2017.
  26. Nursing Process Focus: Clients Receiving Beta-Adrenergic Antagonist Therapy. Updated: January 1, 2010. Accessed: April 7, 2017.
  27. Langan R, Jones K. Common Questions About the Initial Management of Hypertension. Am Fam Physician. 2015; 91 (3): p.172-177.
  28. Pflieger M, Winslow BT, Mills K, Dauber IM. Medical Management of Stable Coronary Artery Disease. Am Fam Physician. 2011; 83 (7): p.819-826.
  29. Rosenson RS, Reeder GS, Kennedy HL. Acute myocardial infarction: Role of beta blocker therapy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: June 15, 2016. Accessed: April 8, 2017.
  30. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary. Circulation. 2014; 130 (25): p.2354-2394.doi: 10.1161/cir.0000000000000133 . | Open in Read by QxMD
  31. Kannam JP, Aroesty JM, Gersh BJ. Beta blockers in the management of stable ischemic heart disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: September 21, 2016. Accessed: February 23, 2017.
  32. Giardina EG. Therapeutic use and major side effects of sotalol. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: November 2, 2016. Accessed: April 8, 2017.
  33. Sotalol. Updated: April 8, 2017. Accessed: April 8, 2017.
  34. Hedera P, Cibulčík F, Davis TL. Pharmacotherapy of essential tremor. J Cent Nerv Syst Dis. 2013; 5: p.43-55.doi: 10.4137/JCNSD.S6561 . | Open in Read by QxMD
  35. Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006; 73 (1): p.72-78.
  36. Hong J, Bernstein D. A Review of Drugs That Induce or Exacerbate Psoriasis. Psoriasis Forum. 2012; 18 (1).
  37. Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008; 51 (4): p.960-969.doi: 10.1161/HYPERTENSIONAHA.106.075895 . | Open in Read by QxMD
  38. Ph A. Management of hypertension in pregnant and postpartum women. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: April 4, 2017. Accessed: April 8, 2017.
  39. Beta-Adrenoceptor Antagonists (Beta-Blockers). Updated: January 29, 2016. Accessed: February 22, 2017.
  40. Poirier L, Tobe SW. Contemporary use of β-blockers: clinical relevance of subclassification. Can J Cardiol. 2014; 30 (5 Suppl): p.S9-S15.doi: 10.1016/j.cjca.2013.12.001 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer