Selective Use of Nonselective Beta-Blockers

Beta-blockers (BBs) are a cornerstone of antiarrhythmic therapy, yet assuming a uniform "class effect" oversimplifies their diverse pharmacological properties and might compromise efficacy. This review synthesizes evidence comparing the antiarrhythmic effects of different BBs in various clinical settings. While cardioselective agents offer improved tolerability, they often fail to blunt the broad adrenergic surge driving specific arrhythmias. Nonselective BBs (eg, nadolol, propranolol) provide superior efficacy in inherited channelopathies, such as catecholaminergic polymorphic ventricular tachycardia and long QT syndrome, and life-threatening electrical storms. Furthermore, carvedilol is superior to metoprolol for preventing postoperative atrial fibrillation and reducing inappropriate shocks in patients with implantable cardioverter-defibrillators. Conversely, for managing chronic supraventricular tachycardia, cardioselective agents remain preferred. By leveraging distinct BB properties, clinicians can overcome the "one-size-fits-all" approach and tailor therapy to optimize antiarrhythmic efficacy. More research is needed to resolve uncertainties and assist clinicians in adopting a personalized approach to BBs therapy.