However, in each case minimal evidence supports the risk of exacerbating disease and in most cases the benefits of therapy outweigh risks. OthersĬlinicians may be cautioned against using beta blockers in a number of other disease states, including diabetes mellitus, peripheral vascular disease, depression, and erectile dysfunction. However, beta blockers need not be avoided in patients with chronic obstructive pulmonary disease (COPD) given lack of evidence to indicate harm and a potential benefit. Pulmonary diseaseĬalcium channel blockers should be favored over beta blockers in patients with asthma (or other forms of pulmonary disease with a bronchospastic component) given the risk of exacerbating bronchospasm. The addition of a nondihydropyridine calcium channel blocker should generally be avoided in patients who are already receiving a dihydropyridine calcium channel blocker (e.g., amlodipine, nifedipine), as only a minimal incremental impact on blood pressure is observed. Therefore, in patients with concomitant high blood pressure who may benefit from additional blood pressure lowering, calcium channel blockers may be a more ideal option for rate control. Beta blockers should be reserved for patients whose blood pressure remains uncontrolled despite use of the four preferred drug classes (ACEi or ARB, thiazide, or calcium channel blocker) given evidence from trials that they are less effective at preventing cardiovascular events. HypertensionĪlong with angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), and thiazide diuretics, calcium channel blockers are recommended as a first-line option for patients with high blood pressure . Their use as initial therapy is especially advocated in black patients (although thiazides are a viable alternative), given improvements in long-term cardiovascular events compared to inhibitors of the renin-angiotensin-aldosterone system. Notably the benefits of beta blockers in the post-MI setting appear to attenuate over time, though they remain a standard of care and should be favored over non-dihydropyridine calcium channel blockers. The latter remain an option in patients with chronic stable angina or those whose symptoms are refractory to maximally-tolerated doses of beta blockers. Ischemic heart diseaseĪlthough both classes are associated with improvements in major adverse cardiovascular events in patients with a history of myocardial infarction (MI), only beta blockers have been associated with reductions in the incidence of ventricular arrhythmias and sudden cardiac death. For these reasons, the use of non-dihydropyridine calcium channel blockers should generally be avoided in patients with HFrEF despite minimal differences in their acute risks. However, long-term beta blocker use confers significant improvements in survival whereas non-dihydropyridine calcium channel blockers either exert no beneficial effects or may even worsen outcomes. Heart failureīoth beta blockers and non-dihydropyridine calcium channel blockers exert negative inotropic effects in the acute setting and should therefore be used with caution in patients with heart failure with reduced ejection fraction (HFrEF).
The following are several common comorbidities of AF where one agent may be more ideal over another: 1. As a consequence, judicious selection of initial therapy may therefore avoid unnecessarily prolonging a patient’s hospitalization while therapy is transitioned.
While acute rate control is certainly an important therapeutic goal for patients in AF with RVR, consideration of the patient’s comorbid conditions may be just as important for determining which drug class represents a more viable long-term solution.
Thinking Beyond the Emergency DepartmentĪlthough clinicians are cautioned regarding their use in heart failure or hypotension, minimal guidance is provided on which of the two classes is most appropriate in an individual patient. In a previous post, Bryan Hayes ( provided an overview of the data comparing beta blockers to calcium channel blockers for atrial fibrillation rate control in the ED. Here is part 2 of our two-part AF series.
Intravenous beta blockers and non-dihydropyridine calcium channel blockers are recommended first-line for atrial fibrillation (AF) with rapid ventricular rate (RVR).
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