Beta-blockers are key in the management of cardiovascular diseases but blocking airway β₂-receptors can cause severe and sometimes fatal bronchoconstriction in people with asthma. Although cardioselective β₁-blockers may be safer than non-selective β-blockers, they remain relatively contraindicated and under-prescribed. We review the evidence of the risk associated with cardioselective β₁-blocker use in asthma.

We searched “asthma” AND “beta-blocker” in PubMed and EmbaseOvid from start to May 2020. The World Health Organization (WHO) global database of individual case safety reports (VigiBase) was searched for reports of fatal asthma or bronchospasm and listed cardioselective β₁-blocker use (accessed February 2020). Reports were examined for evidence of pre-existing asthma.

PubMed and EmbaseOvid searches identified 304 and 327 publications, respectively. No published reports of severe or fatal asthma associated with cardioselective β₁-blockers were found. Three large observational studies reported no increase in asthma exacerbations with cardioselective β₁-blocker treatment. The VigiBase search identified five reports of fatalities in patients with pre-existing asthma and reporting asthma or bronchospasm during cardioselective β₁-blocker use. Four of these deaths were unrelated to cardioselective β₁-blocker use. The circumstances of the fifth death were unclear.

There were no published reports of cardioselective β₁-blockers causing asthma death. Observational data suggest that cardioselective β₁-blocker use is not associated with increased asthma exacerbations. We found only one report of an asthma death potentially caused by cardioselective β₁-blockers in a patient with asthma in a search of VigiBase. The reluctance to use cardioselective β₁-blockers in people with asthma is not supported by this evidence.