Beta blockers may be considered as initial therapy for hypertension particularly if intolerant or C/I to ACEI/ARB for:
• younger people (under 55)
• women of childbearing age
• people with evidence of increased sympathetic drive
• at Step 4 if further diuretic therapy is not tolerated, C/I or ineffective

Evidence suggests the combination of beta-blocker and thiazide increases risk of Type 2 DM and this is generally considered to be dose related.
Cardioselective beta-blockers may be used in well-controlled asthmatic patients, or COPD without significant reversible component for Heart Failure or following an MI. Treatment should be initiated at a low-dose & the patient monitored carefully for adverse effects.
Recent evidence-based guidance for angina states that beta-blockers should be the first line therapy for the long-term prevention of angina.
Patients with heart failure should only be prescribed with beta-blockers licensed for this indication.

NICE guidance on Atrial Fibrillation:

Offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker (diltiazem or verapamil) as initial rate-control monotherapy to people with atrial fibrillation unless the person has the features described in recommendation 1.7.4.
Base the choice of drug on the person’s symptoms, heart rate, comorbidities and preferences. [2021]

For people with atrial fibrillation and concomitant heart failure, follow the recommendations on the use of beta-blockers and avoiding calcium-channel blockers in NICE’s guideline on chronic heart failure. [2021]

If monotherapy does not control the person’s symptoms, and if continuing symptoms are thought to be caused by poor ventricular rate control, consider combination therapy with any 2 of the following:
• a beta-blocker
• diltiazem
• digoxin. [2021] In April 2021, this was an off-label use of diltiazem. See NICE’s information on prescribing medicines.

In people with atrial fibrillation presenting acutely with suspected concomitant acute decompensated heart failure, seek senior specialist input on the use of beta-blockers and do not use calcium-channel blockers. [2021]

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Beta-adrenoceptor blockers, selectiveBisoprolol
1.25mg tablet: £0.74For hypertension and angina.

Adult: Initially 5 mg once daily, usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.

For adjunct in heart failure.

Adult: Initially 1.25 mg once daily for 1 week, dose to be taken in the morning, then increased if tolerated to 2.5 mg once daily for 1 week, then increased if tolerated to 3.75 mg once daily for 1 week, then increased if tolerated to 5 mg once daily for 4 weeks, then increased if tolerated to 7.5 mg once daily for 4 weeks, then increased if tolerated to 10 mg once daily.

For post myocardial infarction (off-label).
2.5mg tablet: £1.06
3.75mg tablet: £0.84
5mg tablet: £0.72
7.5mg tablet: £0.90
10mg tablet: £0.78
Atenolol25mg tablet: £1.31
For hypertenion.

Adult: 25–50 mg daily, higher doses are rarely necessary.

For angina.

Adult: 100 mg daily in 1–2 divided doses.
50mg tablet: £1.23
100mg tablet: £1.11
25mg/5ml oral solution sugar free: £10.47 (300ml)
Metoprolol50mg tablet: £1.48

For hypertension.

Adult: Initially 100 mg daily, increased if necessary to 200 mg daily in 1–2 divided doses, high doses are rarely required; maximum 400 mg per day.

For angina.

Adult: 50–100 mg 2–3 times a day.

For post myocardial infarction (off-label).

The 50mg tablet can be divided into equal doses as the 25mg tablet is not cost effective.
100mg tablet: £2.06
Sotalol is no longer recommended for Atrial fibrillation.
Beta-adrenoceptor blockers, non-selectivePropranolol10mg tablet: £0.77For migraine prophylaxis.

Adult: 80-240mg daily in divided doses.
40mg tablet: £0.79
80mg tablet: £1.58 (56)
10mg/5ml oral solution sugar free: £33.21 (150ml)
40mg/5ml oral solution sugar free: £45.82 (150ml)