Cardioselective β-Blockers Generally Are Safe in Asthma Patients

April 22, 2014

Cardioselective β-Blockers Generally Are Safe in Asthma Patients

  1. David J. Amrol, MD

However, patients should still be warned about possible early asthma worsening.

  1. David J. Amrol, MD

β-blockers can cause airway obstruction and even severe exacerbations in asthma patients. The mechanism of action is presumed to be catecholamine antagonism at the pulmonary β2-receptor with resulting unopposed cholinergic tone causing bronchoconstriction. However, a 2002 Cochrane review concluded that, in patients with mild-to-moderate asthma, cardioselective β-blockers did not confer substantial short-term respiratory effects and should not be withheld from asthma patients with heart disease (Cochrane Database Syst Rev 2002; 4:CD002992).

Researchers performed a meta-analysis (32 studies with 548 adult patients) to examine the effect of cardioselective and nonselective β-blockers on lung function and symptoms in patients treated for 1 to 7 days. In a dose-responsive manner, selective β-blockers caused a mean 7% absolute drop in forced expiratory volume in 1 second (FEV1) and attenuated β-agonist response by a mean of 10%. One in 8 patients experienced decreases in FEV1 of ≥20%, and 1 in 33 patients experienced worsened asthma symptoms. Nonselective β-blockers caused a mean 10% drop in FEV1 and attenuated β-agonist response by 20%. One in 9 patients experienced absolute decreases in FEV1 of ≥20%, and 1 in 13 patients had worsened asthma symptoms. Drug-specific differences were noted: celiprolol (not available in the U.S.) had the least effect; atenolol and metoprolol (selective agents) and labetalol and propranolol (nonselective agents) had sequentially greater effects.


This analysis offers further support for using cardioselective β-blockers in patients with stable asthma who have clear indications for the drug, but nonselective β-blockers should be avoided if possible. Because even cardioselective agents can reduce FEV1 and can interfere with drug effectiveness, patients with unstable asthma should not receive β-blockers. Physicians should be aware that a few asthma patients will experience worsening asthma symptoms and substantial declines in lung function while receiving the first few doses of cardioselective β-blockers.

Editor Disclosures at Time of Publication

  • Disclosures for David J. Amrol, MD at time of publication Consultant / advisory board Dyax Leadership positions in professional societies South Carolina Allergy Society (President)


Reader Comments (6)

Amrol, David

The Cochrane study was 2002, but this study was just published. After 7 days the adverse pulmonary effects were no longer evident. We need to be vigilant the first few days, but long term they seem very safe when tolerated the first week.

dr.r.krishna chetty,M.D;F.C.C.P; Physician, Internal Medicine, salem,india

indian pts are more prone for acute bronchospastic attacks due to even highly cardio selective beta blockers;even non asthmatics had developed bronchospasm;
ilike to know the advantage of nebivelol and bisoprolol over others in this situations;

Srikanta Mahapatra, M.D. Physician, Internal Medicine, S.E.Railway Hospital, Kharagpur, India

Among the beta 1 selective BBs Nebivolol appears to be the best tolerated amongst patients with CAD and Asthma/COPD. Metoprolol does worsen symptoms in few of these patients and Atenolol the worst.

Koretzky Martin Horacio Physician, Cardiology, Private consulting office

The dose is important in regards to cardioselectivity, at higher doses the selectivity is lost. In Argentina we can use two good beta blockers as nebivolol and bisoprolol, always begin at low doses. Aproximatly 20% of patients won't tolerate them. And remember that carvedilol is not cardioselective, we use it allot in patients with heart failure, and I frequently recieve asmatic patients with bronchospasm on this treatment.

David L Keller, MD, MS, FACP Physician, Internal Medicine, Outpatient

Even cardioselective beta blockers caused significant and measurable worsening of asthma symptoms and objective pulmonary function measurements. The asthmatics with coronary disease whose lives are saved by beta blockers may never know or appreciate the calculated risk their physician took in prescribing them. However, if an asthmatic suffers a coronary event after receiving a selective beta blocker, it could be blamed on an increase in myocardial ischemia triggered by the respiratory adverse effects of the beta blocker. Even a small reduction in FEV1 could be blamed for converting a stable coronary syndrome into an unstable one. Who can tell for certain after-the-fact? Physicians who prescribe even highly selective beta blockers to asthmatics should thoroughly document their reasoning, and would be wise to consult with a cardiologist and a pulmonologist in these cases.


This study was done in 2002 its only now you a're letting people know? How come

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