Table 3.

Review of guidelines for the treatment of CVDs and COPD separately [55–64]

Condition		Guideline Source	Recommendation	CoR	LOE
CVD	Hypertension	2023 European Society of Hypertension Guidelines for the Management of Arterial Hypertension [57]	To prevent AF in hypertension, β-blockers may be considered in combination with renin–angiotensin system blockers	II	B
			To treat hypertension in AF, β-blockers are the preferred drug class for heart rate control	I	B
			When treating hypertension in AF, β-blockers should not be combined with NDCCBs	III	C
		2024 European Society of Cardiology Guidelines for the Management of Elevated Blood Pressure and Hypertension [55]	Among all blood pressure-lowering drugs, ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide) have demonstrated the most effective reduction blood pressure and cardiovascular events, and are therefore recommended as first-line treatments to lower blood pressure	I	A
			It is recommended that β-blockers are combined with any of the other major blood pressure-lowering drug classes when there are other compelling indications for their use, e.g., angina, post-myocardial infarction, HF with reduced ejection fraction, or heart rate control	I	A
			In patients with a history of myocardial infarction who require blood pressure-lowering treatment, β-blockers and RAS blockers are recommended as part of treatment	I	A
			In patients with symptomatic angina who require blood pressure-lowering treatment, β-blockers and/or CCBs are recommended as part of that treatment	I	A
			In patients with symptomatic HFreF/HFmrEF, the following treatment with blood pressure-lowering effects are recommended to improve outcomes: ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) or angiotensin receptor-neprilysin inhibitors, β-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter type 2 inhibitors	I	A
	STEMI	American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [59]	In patients with STEMI without signs of HF or evidence of a low-output state, increased risk for cardiogenic shock, or other contraindications, β-blockers should be initiated in the first 24 h	I	B
			β-blockers should be continued during and after hospitalization for all patients with STEMI and with no contraindications to their use	I	B
			Patients with initial contraindications to β-blockers in the first 24 h after STEMI should be reevaluated to determine their subsequent eligibility	I	C
			It is reasonable to administer β-blockers at the time of STEMI presentation in patients with no contraindications who are hypertensive or have ongoing ischemia	IIa	B
	NSTE-ACS	AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes [60]	In non-STEMI, β-blockers should be initiated within the first 24 h when there are no signs of HF, evidence of a low-output state, an increased risk of cardiogenic shock, or other contraindications	I	A
			In patients with concomitant NSTE-ACS, stabilized HF, and reduced systolic function, it is recommended to continue β-blockers with either metoprolol, carvedilol, or bisoprolol	I	C
			Patients with contraindications to β-blockers in the first 24 h of NSTEMI should be reevaluated to determine sequent eligibility	I	C
			It is reasonable to continue β-blockers in patients with normal LV function with NSTEMI	IIa	C
	Pre-HF	2022 ACC/AHA Joint Committee on Clinical Practice Guidelines [61]	In pre-HF, in patients with a recent/remote history of myocardial infarction or acute coronary syndrome and LVEF fraction ≤ 40%, β-blockers reduce mortality	I	B-R
	HFpEF	The Korean Society of Heart Failure Guidelines [62]	β-blockers may reduce cardiovascular mortality	IIb	C
	HFmrEF	The Korean Society of Heart Failure Guidelines [62]	β-blockers may reduce cardiovascular mortality	IIb	C
		2022 ACC/AHA Joint Committee on Clinical Practice Guidelines [61]	Among patients with current/previous symptomatic HFmrEF (LVEF 41–49%), β-blockers reduce the risk of HF hospitalization and cardiovascular mortality	IIb	B-NR
	HFrEF	The Korean Society of Heart Failure Guidelines [62]	β-blockers are considered part of the standard of care for reducing symptoms, cardiovascular mortality, and heart failure hospitalization	I	A
			β-blockers reduce mortality in randomized clinical trials, including bisoprolol, carvedilol, and metoprolol	I	A
			In patients aged ≥ 70 years, nebivolol may be beneficial	IIa	B
		2022 ACC/AHA Joint Committee on Clinical Practice Guidelines [61]	In HFrEF with current or previous symptoms, use of one of the three β-blockers proven to reduce mortality (bisoprolol, carvedilol, metoprolol) is recommended to reduce mortality and hospitalization	I	A
			In HFrEF with current or previous symptoms, β-blockers provide high economic value	Value statement: high value (A)
	AF	2023 ACC/AHA/American College of Clinical Pharmacy/Heart Rhythm Society Guidelines for the Diagnosis and Treatment of Atrial Fibrillation [58]	In AF with a rapid ventricular response but stable hemodynamics, β-blockers are recommended for acute rate control	I	B-R
			In pregnant individuals with persistent AF, β-blockers with a record of safety in pregnancy (e.g., propranolol and metoprolol) are reasonable as first-line agents	2a	B-NR
COPD	Prevention of COPD exacerbations	The Department of Veterans Affairs and Department of Defense [63]	If the diagnosis is confirmed but the patient is not having an acute exacerbation, prevention and risk reduction methods (e.g., smoking cessation and patient education) are offered first	NA	NA
		The American Thoracic Society [64]	In COPD with dyspnea or exercise intolerance, LABA/LAMA combination therapy is recommended over monotherapy	Strong	Moderate
	Treatment for acute exacerbations	Global Initiative for Chronic Obstructive Lung Disease [56]	SABAs are recommended as the initial bronchodilators to treat acute COPD exacerbation		C
		The Department of Veterans Affairs and Department of Defense [63]	If the patient presents to primary care with acute exacerbation, initiate SABA If symptoms resolve, consider continuing SABA therapy or initiating LABA, steroid, or antibiotic therapy	NA	NA
	Treatment for patients with previous exacerbations	Global Initiative for Chronic Obstructive Lung Disease [56]	Patients with 0–1 moderate exacerbations (not hospitalized) should be treated with a bronchodilator if the mMRC score is 0–1 and CAT score is < 10, or a LABA/LAMA if the mMRC score is ≥ 2 and CAT score is ≥ 10	NA	NA
			For ≥ 2 moderate exacerbations or ≥ 1 exacerbation leading to hospitalization, a LAMA is recommended if the mMRC score is 0–1 and CAT score is < 10, and LAMA, LAMA + LABA, or ICS + LABA is recommended if the mMRC score is ≥ 2 and the CAT score is ≥ 10. After, a review, assess, adjust approach is adopted	NA	NA
		The Department of Veterans Affairs and Department of Defense [63]	If the patient is chronically symptomatic and/or has a moderate to severe exacerbation in the past year, use SABA with the following to increase intensity: first-line LAMA; add LABA for severe symptoms; add ICS only for continued moderate to severe exacerbations
		The American Thoracic Society [64]	If dyspnea/exercise intolerance despite dual therapy, triple therapy with ICS/LABA/LAMA is recommended in patients with a history of ≥ 1 exacerbation in the past year or hospitalization	Conditional	Moderate
			In patients with COPD receiving triple therapy, ICS can be withdrawn if no exacerbations in the past year	Conditional	Moderate

ACE angiotensin-converting enzyme, AF atrial fibrillation, ARB angiotensin receptor blocker, B-NR level of evidence B with data derived from nonrandomized trials or meta-analyses of such trials, B-R level of evidence B with data derived from randomized trials or meta-analyses of such trials, CAD coronary artery disease, CAT COPD Assessment Test, CCB calcium channel blocker, CoR class of recommendation, HF heart failure, HFmrEF heart failure with mid-range ejection fraction, HFpEF heart failure with preserved ejection fraction, HFrEF heart failure with reduced ejection fraction, ICS inhaled corticosteroid, LABA long-acting β-agonist, LAMA long-acting muscarinic antagonist, LOE level of evidence, mMRC modified Medical Research Council, NA not applicable, NSTEMI non-ST-segment elevation myocardial infarction, RAS renin–angiotensin system, SABA short-acting β-agonist, STEMI ST-segment elevation myocardial infarction