Should You Worry About Beta Blockers?

(This article appeared previously on MedShadow.org.)

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 No. 1 use of beta blockers in the country is to treat hypertension; that’s because of the sheer numbers of people with hypertension,” says Dr. Raymond Bietry, a heart failure specialist at Mount Sinai hospital in New York City. “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 a treatment for high blood pressure if you have no other risk factors for heart disease.

A study published in the Journal of the American Medical Association found that beta blockers do not reduce the rate of heart attacks in individuals considered at risk of having one. But they do reduce the rate of death among those who’ve already suffered heart attacks.

Still, beta blockers are among the most commonly prescribed medications in the U.S. — tens of millions of people 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 high blood pressure, 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 Dr. Andrew Freeman,  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. Also talk about the side effects you might experience and what you can do about them.

“You’ve heard of the body’s flight-or-fight response?” asks Bietry. “That response gets switched on when your body is under some form of stress." Beta receptors, which exist in a lot of different tissue, including cardiac tissue, are activated. Adrenaline 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 that 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 block the effects of adrenaline (also known as the hormone epinephrine) and other neurohormones; slow down heart rate and allow the heart to beat with less force. They also work to open up blood vessels, improving blood flow.

Different beta blockers work on different parts of the body. A doctor may prescribe carvedilol (sold as Coreg) for a patient with chronic stable angina or another who recently had a heart attack. Or she might give bisoprolol (Zebeta) to another patient who is experiencing frequent migraines. A glaucoma patient may get timolol (Timoptic, Istalol and Betimol). When selecting beta blockers, doctors also consider the patient’s medical history and any other medications he or she is currently taking.

If you have high blood pressure, explains Bietry, other hypertensive meds are a smarter, more benign choice.

Diuretics (water pills) and lifestyle changes are often the first steps for lowering blood pressure. The latter includes losing a modest amount of weight, exercising, managing stress and quitting smoking.

Beta blockers are typically introduced to the treatment regimen if the other methods alone aren’t effective. All beta blockers have been FDA-approved to treat high blood pressure; to date, no study has shown one to be more effective than the others. Individual circumstances ultimately guide the selection of treatment options.

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.”

Beta blockers, like all medications, come with a host of possible side effects.

Troubling side effects that are worthy of being promptly addressed include:

• Cold hands and feet
• Headaches
• Constipation or diarrhea
• Nausea
• Erectile dysfunction or loss of sex drive (in both genders)
• Fatigue

More serious side effects include:

• Shortness of breath or difficulty breathing (bronchial spasm)
• Dizziness
• Trouble sleeping
• Depression

“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 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 is of particular concern among older patients. Falls among elderly patients can have catastrophic consequences. They can cause traumatic brain injury, bone fractures (particularly of the hip) and dislocated joints that severely limit mobility and even death.

Research shows that older people who take beta blockers and other antihypertensive medications (including diuretics, calcium channel blockers, renin-angiotensin system blockers and others) have a “significantly higher” risk of serious fall injuries compared to their peers who don’t. Therefore, doctors do not recommend they take these drugs for the sole purpose of lowering blood pressure.

Some people experience depression after going on a beta blocker, and that is one side effect that’s more complex.

“It’s tough to figure out the interaction between the medication and depression,” says 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. For example, patients with asthma or COPD are often advised to not take beta blockers. But one particular beta blocker, metoprolol, has been shown to be less irritating and is often well-tolerated by those with non-severe asthma. (Earlier this year the FDA approved ivabradine, often sold as Corlanor, which can be an alternative to beta blockers for heart failure patients only; it does not cause shortness of breath.)

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.

There are three 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. At least one study found an association between beta blocker usage (whether for glaucoma or another condition) and the development of cataracts. However, because cataracts are more treatable than glaucoma most ophthalmologists keep beta blockers in their treatment protocols.
• 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. Fatigue and exhaustion are two main concerns and your doctor may need to try different doses to bring relief with minimal side effects.
• To ease performance anxiety: Going back to Bietry’s “flight-or-fight” response explanation, beta blockers block the nerves that stimulate 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.

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 improve lung cancer survival rates. In one 2012 study, for example, patients with non-small-cell lung cancer who were being treated with radiation lived 22 percent longer if they were also taking beta blockers. That’s compared to patients who were only treated with radiation. There’s also ongoing research that explores what role, if any, beta blockers might play in the treatment of post traumatic stress disorder.

It’s possible — though the jury’s still out on this — that even more Americans will end up on a drug to lower blood pressure, thanks to early results from a long-term study.

In September, federal health officials put an early end to what’s known as the SPRINT study. SPRINT, the Systolic Blood Pressure Intervention Trial, was sponsored by the National Institutes of Health. Since 2009 it has been exploring whether lowering systolic blood pressure even more than is currently recommended would have an effect on rates of cardiovascular disease.

The NIH ended the study early because the evidence was overwhelming. Adults in the study who got their systolic pressure down to 120 reduced rates of heart attack, heart failure and stroke by almost a third. (The previous recommendation for most people was a systolic reading of 140 or below.)

What’s still unclear is whether the new guidelines might spur an increase in how often doctors prescribe blood pressure-lowering beta-blockers. (The experts interviewed for this story said it was too soon to tell.)

Going back to the primary reason beta blockers are prescribed in the United States — cardiovascular health — Freeman emphasizes that lifestyle trumps everything.

It’s rare in the U.S. for a someone who’s had a heart attack or who suffers from dangerously high blood pressure to get off medications, including beta blockers, completely. But it’s not impossible. Freeman cited one 50-year-old male patient who’d suffered a pretty decent-sized heart attack and, as Freeman puts it, “saw the light.” He made such significant lifestyle changes with diet and exercise that he needs just a tiny dose of a beta blocker.

The No. 1 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,” Freeman says. A mostly plant-based diet (less meat, especially red meat, and more vegetables, beans and legumes, etc.) is also key, he says.

The mind-body connection is also important. Being in stressful situations raises your heart attack risk, so it’s smart to take a holistic approach to your health, Freeman says.