Beta-blocker tapering and symptom improvement in dysautonomic dysfunction patients

Background

Beta-blockers are commonly prescribed in dysautonomic dysfunction, but their long-term symptomatic benefit is limited and may impair exercise tolerance. Evidence on the safety and impact of dose tapering during rehabilitation is scarce.

Purpose

To evaluate whether progressive beta-blocker dose reduction during a 6-month cardiac rehabilitation programme improves symptoms and functional capacity in patients with Postural orthostatic tachycardia syndrome (POTS) and inappropriate sinus tachycardia (IST)

Methods

We analysed a prospectively maintained database of 104 patients with dysautonomic dysfunction enrolled in a supervised rehabilitation programme. The cohort comprised mostly women (92.3 %) with a mean age of 27.9 ± 5.5 years and an age range of 19–38 years. Seventy-six patients had POTS and 28 had IST. Cardioselective beta-blockers were commonly used (metoprolol succinate 33 %, metoprolol tartrate 29 %, bisoprolol 28 %, carvedilol 11 %). Baseline assessment included resting heart rate, symptom burden and cardiopulmonary exercise testing. Cardioselective beta-blockers were gradually tapered with monitoring of symptoms, functional capacity and cardiovascular events.

Results

Changes at 6 Months

Mean beta-blocker dose decreased from 50.9 ± 30.5 mg to 9.6 ± 9.0 mg (–80.3 ± 12.4 %). Resting heart rate fell from 94.9 ± 10.7 to 72.3 ± 12.2 bpm (Δ –22.6 ± 6.8). Peak VO₂ increased from 21.4 ± 4.3 to 29.9 ± 6.3 mL·kg⁻¹·min⁻¹ (+39.8 %). Symptom improvement occurred in dizziness (75 %), mild exercise intolerance (81 %), moderate intolerance (60 %), severe intolerance (41 %) and syncope frequency (–40 %). Only 8.7 % experienced orthostatic relapse and programme adherence averaged 82.8 %. No arrhythmic or cardiovascular adverse events were observed over the 6-month follow-up, supporting the safety of beta-blocker tapering when combined with supervised rehabilitation

Conclusions

In a young cohort of patients with POTS or IST undergoing structured rehabilitation, progressive beta-blocker tapering was associated with a substantial reduction in resting heart rate, a 39.8 % increase in peak VO₂, and marked improvements in dizziness and exercise intolerance with low relapse rates and no arrhythmic or cardiovascular adverse events. These findings suggest that tapering beta-blockers within a supervised rehabilitation programme can be safe and may enhance recovery. Symptom improvements were observed across the full spectrum of dose reduction; this highlights the synergistic value of combining beta-blocker tapering with multimodal rehabilitation. Prospective controlled studies are warranted to confirm these observations and to optimise pharmacological strategies in dysautonomic dysfunction management.ESC beta blocker figure 1ESC betablocker tapering figure 2