Cardiovascular Medications: ARBs and Beta Blockers

Introduction to Contraindications and Precautions

Both ARBs and beta blockers have specific contraindications and precautions that must be considered before prescribing, with angioedema being an important contraindication for ARBs and severe bradycardia, heart block, and active bronchospasm being key contraindications for beta blockers, as noted by the American College of Cardiology and other guideline societies 1, 2

Bilateral renal artery stenosis can cause rapid decline in renal function, and patients with a history of angioedema with ACE inhibitors should be cautioned when substituting an ARB, as some patients have also developed angioedema with ARBs 1, 3
Combination with ACE inhibitors and aldosterone antagonists is potentially harmful due to increased risk of hypotension, renal dysfunction, and hyperkalemia, as warned by the American Heart Association and the American College of Cardiology 1, 4, 5
ARBs are contraindicated in patients with known hypersensitivity to ARBs, pregnancy, and co-administration with aliskiren in diabetic patients 1, 6

Severe bradycardia: heart rate too low to support adequate cardiac output, second or third-degree heart block without a pacemaker, cardiogenic shock, decompensated heart failure requiring inotropic support, and active bronchospasm are contraindications for beta blockers, as noted by the American College of Cardiology 2
Risk factors for shock: age >70 years, heart rate >110 beats per minute, systolic BP <120 mmHg, and late presentation should be considered when prescribing beta blockers 2

Monitor blood pressure, renal function, and potassium within 1-2 weeks after initiation of ARBs, with particular caution in patients with diabetes mellitus and impaired renal function, as recommended by the American Heart Association and the American College of Cardiology 1, 4, 5
Cardioselective beta blockers (bisoprolol, metoprolol) are preferred in patients with mild to moderate COPD or diabetes, and evidence-based beta blockers (carvedilol, bisoprolol, metoprolol succinate) should be used in heart failure, as recommended by the American College of Cardiology 2
Temporary withholding of beta blockers may be necessary during acute decompensated heart failure, as noted by the American College of Cardiology 7
Monitoring is necessary when ARBs are used with NSAIDs, as they may reduce the antihypertensive effect and increase the risk of renal dysfunction, according to the American College of Cardiology 8

Blood pressure (including postural changes)
Renal function (serum creatinine, eGFR)
Serum potassium
Signs of angioedema, as recommended by the American Heart Association and the American College of Cardiology 1, 4, 5

Heart rate and blood pressure
Signs of heart failure exacerbation
Respiratory function in patients with pulmonary disease
Blood glucose in diabetic patients, as recommended by the American College of Cardiology 2

No washout period is required, and the ARB can be started immediately at the recommended starting dose, with monitoring of blood pressure, renal function, and potassium within 1-2 weeks after initiation, as recommended by the American Heart Association and the American College of Cardiology 1, 4, 5
Patients with systolic blood pressure <80 mmHg, low serum sodium, diabetes mellitus, impaired renal function, elderly patients, or volume-depleted patients require careful consideration when switching to ARBs, according to the American Heart Association and the European Society of Cardiology 1, 5

The combination of ARB and ACE inhibitor should be avoided due to the increased risk of hyperkalemia and acute kidney injury, as warned by the American Diabetes Association and the American Heart Association 9, 1, 4, 8
ARBs may be considered in combination with evidence-based beta-blockers, especially for patients with left ventricular ejection fraction (LVEF) ≤40% who cannot tolerate ACE inhibitors, with a Class I recommendation and Level of Evidence A, as recommended by the American College of Cardiology 1, 10

ARBs are considered safer alternatives for patients who developed ACE inhibitor-induced cough, but caution is needed with patients who experienced angioedema on ACE inhibitors, as noted by the European Society of Cardiology and the American College of Cardiology 1, 4, 5
ARBs are particularly beneficial in patients with diabetes, chronic kidney disease, or proteinuria, due to their nephroprotective properties, as recommended by the American Heart Association and the American Diabetes Association 11, 9
The American Heart Association recommends ARBs as first-line therapy in patients who are ACE inhibitor intolerant and have heart failure with reduced ejection fraction (HFrEF), myocardial infarction with LVEF ≤40%, or hypertension, with a Class I recommendation and Level of Evidence A, as recommended by the American Heart Association and the American College of Cardiology 1, 11, 12, 10
Alternative therapies to ARBs include ACE inhibitors, calcium channel blockers, and diuretics, which can be considered based on patient-specific factors and comorbidities, as recommended by the American College of Cardiology and the American Heart Association 6, 13
The American Heart Association recommends maintaining appropriate blood pressure targets, generally <130/80 mmHg, in patients receiving therapy, as recommended by the American Heart Association and the American Diabetes Association 13, 9