Selection of beta blocker therapy for patients with cardiovascular disease and comorbid COPD

COPD: chronic obstructive pulmonary disease; HF: heart failure; HFrEF: heart failure with reduced ejection fraction, defined as heart failure with LVEF ≤40%; LVEF: left ventricular ejection fraction; MI: myocardial infarction.

* Patients with LVEF <50% include patients with HFrEF, those with HF with mildly reduced LVEF (LVEF 41 to 49%), and those without HF (ie, asymptomatic LV systolic dysfunction). Specific beta blockers are a key component of the primary therapy for HFrEF; metoprolol and bisoprolol are cardioselective beta blockers shown to reduce risks of mortality and hospitalization and decrease heart failure symptoms. These beta blockers are also used in other patients with LVEF <50%, although the benefit of beta blocker therapy in these other groups is uncertain.

¶ Refer to UpToDate content on the choice between rate and rhythm control for atrial fibrillation and on choice of rate control agent. The most common drug therapy for rate control is a beta blocker or a nondihydropyridine calcium channel blocker. A cardioselective beta blocker is used in patients with COPD who have an additional indication for beta blocker therapy (eg, HFrEF). A nondihydropyridine calcium channel blocker may be preferred for rate control for patients with COPD who have no other indication for beta blocker therapy.

Δ Beta blocker therapy is commonly continued for at least three years following MI, as this therapy may reduce the risk of mortality. Benefit from beta blocker therapy in this setting is most likely in patients with reduced LVEF (LVEF <50%).

◊ A beta blocker is first-line therapy for treatment of most patients with angina. However, a mortality benefit from beta blocker therapy for angina (without HFrEF or MI) has not been established. Also, beta blockers should not be used in patients with vasospastic or variant (Prinzmetal) angina.

§ A beta blocker is generally not a first-line or second-line therapy for hypertension because its use is associated with inferior protection against stroke and mortality risk compared with other antihypertensive agents.