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Exacerbation of angina and, in some cases, myocardial infarction occurrence after abrupt discontinuance. When discontinuing long-term administration of beta blockers particularly with ischemic heart disease, gradually reduce dose over weeks and carefully monitor. If angina markedly worsens or acute coronary insufficiency develops, reinstate beta-blocker administration promptly, at least temporarily in addition to other measures appropriate for unstable angina. Warn patients against interruption or discontinuance of beta-blocker therapy without physician advice. Because coronary artery disease is common and may be unrecognized, slowly discontinue beta-blocker therapy, even in patients treated only for hypertension. Long-term beta blocker therapy should not be routinely discontinued before major surgery; however, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures. Avoid beta-blockers without alpha1-adrenergic receptor blocking activity in patients with prinzmetal variant angina; unopposed alpha-1 adrenergic receptors may worsen anginal symptoms.

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