Beta-blockers are widely used in clinical practice and have a wide range of indications, playing an important role in the treatment of hypertension, arrhythmias, coronary artery disease, and heart failure. However, in elderly patients, its utilization rate in the overall population is low due to various concerns, and its application dose is also low compared to the recommendation of foreign guidelines. In a 2006 survey of primary care physicians in China, the use of beta-blockers in patients with chronic heart failure was only 40.0%, and the target dose was only 1.0%. In a survey of large tertiary care hospitals, the rate of beta-blocker use in outpatients with heart failure could reach 77.5%, but only 2.5% reached the target dose. We start with a specific case of a 75-year-old male admitted to the hospital with acute coronary syndrome and coronary angiography findings of three vessel lesions, followed by PCI with two stents implanted. Previous history of COPD for more than 10 years. On examination: Bp 120/70 mmHg, HR 90 beats/min, a little wet woven P muqi huai hai fang systolic murmur at the base of both lungs, and no swelling of both lower extremities. Echocardiography has segmental ventricular wall motion abnormalities and EF 40%. So should this patient be on a beta-blocker? Let’s start with the following. I. Indications for β-blockers β-blockers are a large class of drugs, which can be broadly divided into non-selective β-blockers and selective β1-blockers. The main ones listed and widely used in China are metoprolol, bisoprolol, carvedilol, atenolol, almare, etc. The only intravenous preparation at present is the short-acting esmolol. Its indications include angina pectoris, myocardial infarction, atrial fibrillation, heart failure, hypertension, mitral valve prolapse, hyperthyroidism, pheochromocytoma (combined with alpha-blockers), migraine, glaucoma, primary tremor, etc. It is also used in aortic coarctation, hypertrophic obstructive cardiomyopathy, portal hypertension, etc. However, the most widely used areas are still cardiovascular system diseases, including coronary heart disease, heart failure and hypertension. Second, the absolute contraindications of β-blockers mainly include the following three points: 1, degree II type II and above atrioventricular block, excluding bundle branch conduction block; 2, bronchial asthma; 3, acute heart failure attack, especially with low blood pressure, pre-cardiogenic shock. Third, the need for β-blockers in elderly cardiac patients In the treatment of heart failure, β-blockers have been the standard of care, with a recommendation level of Class I Class A evidence. Epidemiological surveys have shown that more than 50% of all heart failure patients are older than 75 years of age, making their use more widespread in older heart disease. subgroup analysis of the MERIT-HF study showed that the clinical benefit of applying beta-blockers in older patients (over 75 years of age), with reduced mortality, reduced incidence of sudden death, and reduced rehospitalization rates, was consistent with outcomes in younger patients. In the treatment of coronary artery disease, beta-blockers can slow heart rate, reduce myocardial contractility, lower blood pressure, and thus reduce myocardial oxygen consumption, while reducing heart rate both at rest and after exercise. Studies have shown a 30% reduction in mortality with application in post-infarction patients, but the evidence for improved prognosis in patients with chronic stable angina is not very strong. Therefore, in the 2012 ACCF/AHA guidelines on the diagnosis and treatment of chronic ischemic heart disease, it is stated that category I recommendations include post-infarction EF ≤ 40% and normal post-infarction left ventricular function recommended for 3 years, and longer-term applications are not recommended. And for other types of coronary heart disease is only a Class IIb recommendation. For hypertension treatment, β-blockers can significantly lower blood pressure. However, its effect on lowering blood pressure is significant in younger patients and in those with predominant sympathetic excitation. For elderly hypertensive patients, calcium antagonists and diuretics are more effective in lowering blood pressure. Also in some meta-analyses, beta-blockers were shown to have no significant benefit in reducing mortality and lowering the incidence of cardiovascular events, although most of these trials applied older beta-blockers such as atenolol. In elderly patients with hypertension, there are no other indications for the application of beta-blocker therapy alone. In the combination therapy of hypertension, β-blockers combined with diuretics are effective in lowering blood pressure and can play a synergistic role. Clinicians’ concerns about the use of beta-blockers in elderly patients Elderly patients often have various concerns about the application of beta-blockers due to the reduced function of the body and the combination of various diseases. The first is the heart rate. Due to the degenerative changes in the sinus node, atrioventricular node and cardiac conduction system in elderly patients, the incidence of pathological sinus node syndrome is relatively high, so clinicians are often concerned about the occurrence of slow heart rate, cardiac arrest and severe conduction block, and even the occurrence of As syndrome after the use of beta-blockers. In the CIBIS III study, 1010 patients with mild to moderate heart failure were enrolled, all greater than or equal to 65 years of age, with a mean age of 72 years, meeting the definition of the elderly population. The target dose of bisoprolol in the regimen was 10 mg/day, and it was observed that 65% of the patients could reach the target dose of 10 mg and 82% could reach the dose of 5 mg and above, indicating that the drug was tolerated more than expected in elderly patients.The COLA II study also showed that carvedilol was well tolerated in elderly heart failure patients >70 years old, with an overall tolerability of 80%, and that it was tolerated in patients >80 years old. The overall tolerability of carvedilol in patients >80 years of age was 80%, and the tolerability in patients >80 years of age was still 76.8%. We performed ambulatory electrocardiograms in 149 elderly patients over 80 years of age and found that their mean heart rate was 68.9±8.4 beats/min, which was within the normal heart rate range. In fact, the need for hospitalization due to severe bradycardia and syncope caused by the application of β-blockers is rarely encountered in clinical practice. Early trials have shown that beta-blocker use may have adverse effects on glucolipid metabolism, such as increasing the incidence of new-onset diabetes, aggravating dyslipidemia, and masking hypoglycemic symptoms. However, recent studies have shown that carvedilol, which has a vasodilatory effect, has a neutral or positive effect on dyslipidemia and insulin resistance. In patients with definite type I diabetes, non-selective β-blockers can mask hypoglycemic effects, such as tremor and tachycardia, when selective β1-blockers should be used. For patients with COPD, β-blockers are not a contraindication. COPD often coexists with heart failure or coronary artery disease, and epidemiological surveys show that 37% of deaths in COPD patients are due to cardiovascular disease, which exceeds the proportion of respiratory failure. For patients with COPD combined with coronary heart disease, the application of selective beta1 receptor blockers such as metoprolol and bisoprolol can also reduce mortality, and some studies have shown no significant difference for pulmonary function indicators such as FEV1 relative to placebo. However, some patients have COPD combined with asthma, which is sometimes difficult to identify clinically. Therefore, it is necessary to start with a small dose when applying, and it takes longer to adjust the dose upward, and it is necessary to monitor the changes of dyspnea symptoms. V. How to better apply beta-blockers in elderly patients All patients have individual differences in tolerance to beta-blocker drugs, and generally start with a small dose and gradually adjust the dose upward according to the tolerance. In elderly patients with chronic heart failure, especially in cardiac function class III or IV, their doses are increased more cautiously. In the COPERNICUS study, carvedilol was started at a very small dose of 3.125 mg Bid and increased every 2 weeks until the target dose of 25 mg Bid or the maximum tolerable dose was reached, providing a more reasonable protocol for clinical use. At the same time, to avoid excessive reduction of heart rate, patients need to be reminded to monitor their resting heart rate, i.e., the heart rate should not be less than 55 beats/min when they wake up in the early morning. Some elderly patients with severe bradycardia or conduction block when applying small doses of β-blockers may themselves have an underlying degeneration of conduction system function, and if β-blocker therapy is indeed required, it can be considered after the installation of a pacemaker. In patients with chronic heart failure, β-blockers may continue to be used when their condition worsens. First, the dosage of diuretics and angiotensin-converting enzyme inhibitors (ACEI) should be increased to stabilize the clinical situation. If heart failure worsens further, beta-blockers may be reduced or discontinued as appropriate, and then increased or continued after clinical stabilization. In patients receiving long-term β-blocker therapy, their doses need to be adjusted in a timely manner. The dose should not be increased to achieve the target dose, and the dose can be temporarily reduced for observation when the heart rate is found to be too slow or the blood pressure is low, and sudden discontinuation of the drug should be avoided to avoid withdrawal syndrome. Our practice is to first reduce the original dose by half, and after 2 days, when the heart rate and blood pressure do not rebound significantly, if necessary, the dose can be further reduced by half or completely stopped when it is already a small dose. In fact, complete discontinuation of beta-blockers is also the usual measure in patients on long-term beta-blockers who develop severe bradyarrhythmias or hypotension, and no serious rebound has been observed so far. Finally, returning to that previous clinical case, this elderly patient had coronary artery disease, heart failure (compensated), and a rapid ventricular rate with strong indications for beta-blocker application. The clinical benefit of long-term beta-blocker therapy is significant, improving the patient’s prognosis and reducing cardiovascular events. Clinicians need to have a deeper understanding and appreciation of beta-blockers and apply them more widely and accurately.