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Major side effects of beta blockers

Philip J Podrid, MD, FACC
Section Editor
Samuel Lévy, MD
Deputy Editor
Brian C Downey, MD, FACC


Most of the major adverse effects of beta blocking drugs result from beta-adrenoreceptor blockade. Many signs and symptoms can therefore be induced because the beta receptors affect multiple metabolic and physiologic functions. Other reactions apparently unrelated to beta blockade can occur, but they are uncommon.

The major side effects associated with the use of beta blockers will be reviewed here. Beta blocker intoxication (overdose) and the clinical use of these drugs for the treatment of arrhythmias, hypertension, myocardial infarction, and heart failure are discussed separately. (See "Beta blocker poisoning" and "Choice of drug therapy in primary (essential) hypertension", section on 'Beta blockers' and "Acute myocardial infarction: Role of beta blocker therapy" and "Use of beta blockers in heart failure with reduced ejection fraction".)


Major cardiac effects caused by beta blockade include the precipitation or worsening of congestive heart failure, and significant negative chronotropy.

Heart failure — Beta blockers are an important component of long-term therapy for patients with chronic heart failure and reduced left ventricular systolic function, as these drugs reduce the detrimental effects of excess chronic catecholamine stimulation. However, beta blockers may exacerbate symptoms in patients with acute decompensated heart failure or in those with preexisting myocardial dysfunction and borderline compensation, since the maintenance of cardiac output in such patients depends in part upon sympathetic drive. Hence, beta blockers should not be administered as new therapy until after heart failure is compensated. However, patients already receiving beta blockers can be continued on this therapy if there is decompensated heart failure.

Increased peripheral vascular resistance, induced by nonselective beta blockers, also may contribute to the decline in myocardial function in this setting. On the other hand, drugs with intrinsic sympathetic activity (ISA), such as pindolol, may be less likely to impair myocardial function [1].

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Literature review current through: Nov 2017. | This topic last updated: Aug 22, 2016.
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  1. Taylor SH, Silke B, Lee PS. Intravenous beta-blockade in coronary heart disease: is cardioselectivity or intrinsic sympathomimetic activity hemodynamically useful? N Engl J Med 1982; 306:631.
  2. 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 1996; 334:1349.
  3. 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 2004; 164:1389.
  4. Frishman WH. Drug therapy. Pindolol: a new beta-adrenoceptor antagonist with partial agonist activity. N Engl J Med 1983; 308:940.
  5. Houston MC. Abrupt cessation of treatment in hypertension: consideration of clinical features, mechanisms, prevention and management of the discontinuation syndrome. Am Heart J 1981; 102:415.
  6. 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 1975; 293:416.
  7. Rangno RE, Nattel S, Lutterodt A. Prevention of propranolol withdrawal mechanism by prolonged small dose propranolol schedule. Am J Cardiol 1982; 49:828.
  8. Psaty BM, Koepsell TD, Wagner EH, et al. The relative risk of incident coronary heart disease associated with recently stopping the use of beta-blockers. JAMA 1990; 263:1653.
  9. Lefkowitz RJ, Caron MG, Stiles GL. Mechanisms of membrane-receptor regulation. Biochemical, physiological, and clinical insights derived from studies of the adrenergic receptors. N Engl J Med 1984; 310:1570.
  10. Krukemyer JJ, Boudoulas H, Binkley PF, Lima JJ. Comparison of hypersensitivity to adrenergic stimulation after abrupt withdrawal of propranolol and nadolol: influence of half-life differences. Am Heart J 1990; 120:572.
  11. Dunlop D, Shanks RG. Selective blockade of adrenoceptive beta receptors in the heart. Br J Pharmacol Chemother 1968; 32:201.
  12. Beumer, HM, Hardonk, HJ . Effects of beta-adrenergic blocking drugs on ventilatory function in asthmatics. Eur J Clin Pharmacol 1972; 5:77.
  13. Singh BN, Whitlock RM, Comber RH, et al. Effects of cardioselective beta adrenoceptor blockade on specific airways resistance in normal subjects and in patients with bronchial asthma. Clin Pharmacol Ther 1976; 19:493.
  14. Skinner C, Gaddie J, Palmer KN. Comparison of effects of metoprolol and propranolol on asthmatic airway obstruction. Br Med J 1976; 1:504.
  15. Sirak TE, Jelic S, Le Jemtel TH. Therapeutic update: non-selective beta- and alpha-adrenergic blockade in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure. J Am Coll Cardiol 2004; 44:497.
  16. Khosla S, Kunjummen B, Khaleel R, et al. Safety of therapeutic beta-blockade in patients with coexisting bronchospastic airway disease and coronary artery disease. Am J Ther 2003; 10:48.
  17. Frohlich ED, Tarazi RC, Dustan HP. Peripheral arterial insufficiency. A complication of beta-adrenergic blocking therapy. JAMA 1969; 208:2471.
  18. Simpson FO. Beta-adrenergic receptor blocking drugs in hypertension. Drugs 1974; 7:85.
  19. Zacharias FJ, Cowen KJ, Prestt J, et al. Propranolol in hypertension: a study of long-term therapy, 1964-1970. Am Heart J 1972; 83:755.
  20. Lundvall J, Järhult J. Beta adrenergic dilator component of the sympathetic vascular response in skeletal muscle. Influence on the micro-circulation and on transcapillary exchange. Acta Physiol Scand 1976; 96:180.
  21. Radack K, Deck C. Beta-adrenergic blocker therapy does not worsen intermittent claudication in subjects with peripheral arterial disease. A meta-analysis of randomized controlled trials. Arch Intern Med 1991; 151:1769.
  22. Thadani U, Whitsett TL. Beta-adrenergic blockers and intermittent claudication. Time for reappraisal. Arch Intern Med 1991; 151:1705.
  23. Heintzen MP, Strauer BE. Peripheral vascular effects of beta-blockers. Eur Heart J 1994; 15 Suppl C:2.
  24. Antonis A, Clark ML, Hodge RL, et al. Receptor mechanisms in the hyperglycaemic response to adrenaline in man. Lancet 1967; 1:1135.
  25. Abramson EA, Arky RA, Woeber KA. Effects of propranolol on the hormonal and metabolic responses to insulin-induced hypoglycaemia. Lancet 1966; 2:1386.
  26. Reveno WS, Rosenbaum H. Propranolol and hypoglycaemia. Lancet 1968; 1:920.
  27. Lloyd-Mostyn RH, Oram S. Modification by propranolol of cardiovascular effects of induced hypoglycaemia. Lancet 1975; 1:1213.
  28. Hirsch IB, Boyle PJ, Craft S, Cryer PE. Higher glycemic thresholds for symptoms during beta-adrenergic blockade in IDDM. Diabetes 1991; 40:1177.
  29. Deacon SP, Barnett D. Comparison of atenolol and propranolol during insulin-induced hypoglycaemia. Br Med J 1976; 2:272.
  30. Shorr RI, Ray WA, Daugherty JR, Griffin MR. Antihypertensives and the risk of serious hypoglycemia in older persons using insulin or sulfonylureas. JAMA 1997; 278:40.
  31. Giugliano D, Acampora R, Marfella R, et al. Metabolic and cardiovascular effects of carvedilol and atenolol in non-insulin-dependent diabetes mellitus and hypertension. A randomized, controlled trial. Ann Intern Med 1997; 126:955.
  32. Reid JL, Whyte KF, Struthers AD. Epinephrine-induced hypokalemia: the role of beta adrenoceptors. Am J Cardiol 1986; 57:23F.
  33. Castellino P, Bia MJ, DeFronzo RA. Adrenergic modulation of potassium metabolism in uremia. Kidney Int 1990; 37:793.
  34. Lim M, Linton RA, Wolff CB, Band DM. Propranolol, exercise, and arterial plasma potassium. Lancet 1981; 2:591.
  35. Arthur S, Greenberg A. Hyperkalemia associated with intravenous labetalol therapy for acute hypertension in renal transplant recipients. Clin Nephrol 1990; 33:269.
  36. Nowicki M, Miszczak-Kuban J. Nonselective Beta-adrenergic blockade augments fasting hyperkalemia in hemodialysis patients. Nephron 2002; 91:222.
  37. McCauley J, Murray J, Jordan M, et al. Labetalol-induced hyperkalemia in renal transplant recipients. Am J Nephrol 2002; 22:347.
  38. Gheorghiade M, Eichhorn EJ. Practical aspects of using beta-adrenergic blockade in systolic heart failure. Am J Med 2001; 110 Suppl 7A:68S.
  39. Ko DT, Hebert PR, Coffey CS, et al. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA 2002; 288:351.
  40. Silvestri A, Galetta P, Cerquetani E, et al. Report of erectile dysfunction after therapy with beta-blockers is related to patient knowledge of side effects and is reversed by placebo. Eur Heart J 2003; 24:1928.
  41. Sharma AM, Pischon T, Hardt S, et al. Hypothesis: Beta-adrenergic receptor blockers and weight gain: A systematic analysis. Hypertension 2001; 37:250.
  42. Leslie WS, Hankey CR, Lean ME. Weight gain as an adverse effect of some commonly prescribed drugs: a systematic review. QJM 2007; 100:395.
  43. Stephen SA. Unwanted effects of propranolol. Am J Cardiol 1966; 18:463.
  44. Booth RJ, Wilson JD, Bullock JY. Beta-adrenergic-receptor blockers and antinuclear antibodies in hypertension. Clin Pharmacol Ther 1982; 31:555.
  45. Self-poisoning with beta-blockers. Br Med J 1978; 1:1010.
  46. Frishman W, Jacob H, Eisenberg E, Ribner H. Clinical pharmacology of the new beta-adrenergic blocking drugs. Part 8. Self-poisoning with beta-adrenoceptor blocking agents: recognition and management. Am Heart J 1979; 98:798.