Right to education

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Right_to_education 

 

Education
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The right to education has been recognized as a human right in a number of international conventions, including the International Covenant on Economic, Social and Cultural Rights which recognizes a right to free, compulsory primary education for all, an obligation to develop secondary education accessible to all, on particular by the progressive introduction of free secondary education, as well as an obligation to develop equitable access to higher education, ideally by the progressive introduction of free higher education. Today, almost 75 million children across the world are prevented from going to school each day. As of 2015, 164 states were parties to the Covenant.

The right to education also includes a responsibility to provide basic education for individuals who have not completed primary education from the school and college levels. In addition to these access to education provisions, the right to education encompasses the obligations of the students to avoid discrimination at all levels of the educational system, to set minimum standards of education and to improve the quality of education.

International legal basis

The right to education is reflected in international law in Article 26 of the Universal Declaration of Human Rights and Articles 13 and 14 of the International Covenant on Economic, Social and Cultural Rights. Article 26 states:

"Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit. Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace. Parents have a prior right to choose the kind of education that shall be given to their children."

The right to education has been reaffirmed in the 1960 UNESCO Convention against Discrimination in Education, the 1981 Convention on the Elimination of All Forms of Discrimination Against Women, the 2006 Convention on the Rights of Persons with Disabilities, and the African Charter on Human and Peoples' Rights.

In Europe, Article 2 of the first Protocol of 20 March 1952 to the European Convention on Human Rights states that the right to education is recognized as a human right and is understood to establish an entitlement to education. According to the International Covenant on Economic, Social and Cultural Rights, the right to education includes the right to free, compulsory primary education for all, an obligation to develop secondary education accessible to all in particular by the progressive introduction of free secondary education, as well as an obligation to develop equitable access to higher education in particular by the progressive introduction of free higher education. The right to education also includes a responsibility to provide basic education for individuals who have not completed primary education. In addition to these access to education provisions, the right to education encompasses also the obligation to eliminate discrimination at all levels of the educational system, to set minimum standards, and to improve quality. The European Court of Human Rights in Strasbourg has applied this norm for example in the Belgian linguistic case. Article 10 of the European Social Charter guarantees the right to vocational education.

According Indian constitution under 86th Amendment act 2002 gives a right to free and compulsary education upto 6–14 years of age.

Definition

Education consists of formal institutional instructions. Generally, international instruments use the term in this sense and the right to education, as protected by international human rights instruments, refers primarily to education in a narrow sense. The 1960 UNESCO Convention against Discrimination in Education defines education in Article 1(2) as: "all types and levels of education, (including such) access to education, the standard and quality of education, and the conditions under which it is given."

In a wider sense education may describe "all activities by which a human group transmits to its descendants a body of knowledge and skills and a moral code which enable the group to subsist". In this sense education refers to the transmission to a subsequent generation of those skills needed to perform tasks of daily living, and further passing on the social, cultural, spiritual and philosophical values of the particular community. The wider meaning of education has been recognised in Article 1(a) of UNESCO's 1974 Recommendation concerning Education for International Understanding, Co-operation and Peace and Education relating to Human Rights and Fundamental Freedoms.

"the entire process of social life by means of which individuals and social groups learn to develop consciously within, and for the benefit of, the national and international communities, the whole of their personal capabilities, attitudes, aptitudes and knowledge."

The European Court of Human Rights has defined education in a narrow sense as "teaching or instructions... in particular to the transmission of knowledge and to intellectual development" and in a wider sense as "the whole process whereby, in any society, adults endeavour to transmit their beliefs, culture and other values to the young."

The Abidjan principles were passed in early 2019 and provide comprehensive guiding principles on the intersection between private education and the right to education

Assessment of fulfilment

The fulfilment of the right to education can be assessed using the 4 As framework, which asserts that for education to be a meaningful right it must be available, accessible, acceptable and adaptable. The 4 As framework was developed by the former UN Special Rapporteur on the Right to Education, Katarina Tomasevski, but is not necessarily the standard used in every international human rights instrument and hence not a generic guide to how the right to education is treated under national law.

The 4As

The 4 As framework proposes that governments, as the prime duty-bearers, have to respect, protect and fulfil the right to education by making education available, accessible, acceptable and adaptable. The framework also places duties on other stakeholders in the education process: the child, which as the privileged subject of the right to education has the duty to comply with compulsory education requirements, the parents as the ‘first educators’, and professional educators, namely teachers.

The 4 As have been further elaborated as follows:

• Availability – funded by governments, education is universal, free and compulsory. There should be proper infrastructure and facilities in place with adequate books and materials for students. Buildings should meet both safety and sanitation standards, such as having clean drinking water. Active recruitment, proper training and appropriate retention methods should ensure that enough qualified staff is available at each school.
• Accessibility – all children should have equal access to school services, regardless of gender, race, religion, ethnicity or socio-economic status. Efforts should be made to ensure the inclusion of marginalized groups including children of refugees, the homeless or those with disabilities; in short there should be universal access to education i.e. access to all. Children who fall into poverty should be granted the access of education because it enhances the growth of their mental and social state. There should be no forms of segregation or denial of access to any students. This includes ensuring that proper laws are in place against any child labour or exploitation to prevent children from obtaining primary or secondary education. Schools must be within a reasonable distance for children within the community, otherwise transportation should be provided to students, particularly those that might live in rural areas, to ensure ways to school are safe and convenient. Education should be affordable to all, with textbooks, supplies and uniforms provided to students at no additional costs.
• Acceptability – the quality of education provided should be free of discrimination, relevant and culturally appropriate for all students. Students should not be expected to conform to any specific religious or ideological views. Methods of teaching should be objective and unbiased and material available should reflect a wide array of ideas and beliefs. Health and safety should be emphasized within schools including the elimination of any forms of corporal punishment. Professionalism of staff and teachers should be maintained.
• Adaptability – educational programs should be flexible and able to adjust according to societal changes and the needs of the community. Observance of religious or cultural holidays should be respected by schools in order to accommodate students, along with providing adequate care to those students with disabilities.

A number of international NGOs and charities work to realise the right to education using a rights-based approach to development.

Historical development

In Europe, before the Enlightenment of the eighteenth and nineteenth century, education was the responsibility of parents and the church. With the French and American Revolution, education was established also as a public function. It was thought that the state, by assuming a more active role in the sphere of education, could help to make education available and accessible to all. Education had thus far been primarily available to the upper social classes and public education was perceived as a means of realising the egalitarian ideals underlining both revolutions.

However, neither the American Declaration of Independence (1776) nor the French Declaration of the Rights of Man and of the Citizen (1789) protected the right to education, as the liberal concepts of human rights in the nineteenth century envisaged that parents retained the primary duty for providing education to their children. It was the states obligation to ensure that parents complied with this duty, and many states enacted legislation making school attendance compulsory. Furthermore, child labour laws were enacted to limit the number of hours per day children could be employed, to ensure children would attend school. States also became involved in the legal regulation of curricula and established minimum educational standards.

In On Liberty John Stuart Mill wrote that an "education established and controlled by the State should only exist, if it exists at all, as one among many competing experiments, carried on for the purpose of example and stimulus to keep the others up to a certain standard of excellence." Liberal thinkers of the nineteenth century pointed to the dangers to too much state involvement in the sphere of education, but relied on state intervention to reduce the dominance of the church, and to protect the right to education of children against their own parents. In the latter half of the nineteenth century, educational rights were included in domestic bills of rights. The 1849 Paulskirchenverfassung, the constitution of the German Empire, strongly influenced subsequent European constitutions and devoted Article 152 to 158 of its bill of rights to education. The constitution recognised education as a function of the state, independent of the church. Remarkable at the time, the constitution proclaimed the right to free education for the poor, but the constitution did not explicitly require the state to set up educational institutions. Instead the constitution protected the rights of citizens to found and operate schools and to provide home education. The constitution also provided for freedom of science and teaching, and it guaranteed the right of everybody to choose a vocation and train for it.

The nineteenth century also saw the development of socialist theory, which held that the primary task of the state was to ensure the economic and social well-being of the community through government intervention and regulation. Socialist theory recognised that individuals had claims to basic welfare services against the state and education was viewed as one of these welfare entitlements. This was in contrast to liberal theory at the time, which regarded non-state actors as the prime providers of education. Socialist ideals were enshrined in the 1936 Soviet Constitution, which was the first constitution to recognise the right to education with a corresponding obligation of the state to provide such education. The constitution guaranteed free and compulsory education at all levels, a system of state scholarships and vocational training in state enterprises. Subsequently, the right to education featured strongly in the constitutions of socialist states. As a political goal, right to education was declared in F. D. Roosevelt's 1944 speech on the Second Bill of Rights.

The role of education for individuals, the society and the state

Education in all its forms (informal, non-formal, and formal) is crucial to ensure human dignity of all individuals. The aims of education, as set out in the International human rights law (IHRL), are therefore all directed to the realization of the individual’s rights and dignity. These include, among others, ensuring human dignity and the full and holistic development of the human personality; fostering physical and cognitive development; allowing for the acquisition of knowledge, skills, and talents; contributing to the realization of the full potential of the individual; enhancing self-esteem and increasing confidence; encouraging respect for human rights; shaping a person’s sense of identity and affiliation with others; enabling socialization and meaningful interaction with others; enabling a person to shape the world around them enables their participation in community life; contributing to a full and satisfying life within society; and empowering and allowing for the increased enjoyment of other human rights.

The multiple benefits of education

Education is also transformative for the state and society. As one of the most important mechanisms by which social groups, in particular indigenous peoples and minorities are maintained from generation to generation, passing on language, culture, identity, values, and customs, education is also one of the key ways states can ensure their economic, social, political, and cultural interests.

The main role of education within a society and the state is to:

• Allow for the transmission of culture, values, identity, languages, and customs from one generation to the next;
• Promote sustainable economic growth;
• Foster democratic and peaceful societies;
• Encourage participation and inclusion in decision-making processes;
• Encourage a rich cultural life;
• Help build a national identity;
• Promote social justice aims;
• Overcome persistent and entrenched challenges;
• Encourage sustainable development, including respect for the environment.

Implementation

International law does not protect the right to pre-primary education and international documents generally omit references to education at this level. The Universal Declaration of Human Rights states that everyone has the right to education, hence the right applies to all individuals, although children are considered as the main beneficiaries.

The rights to education are separated into three levels:

• Primary (Elemental or Fundamental) Education. This shall be compulsory and free for any child regardless of their nationality, gender, place of birth, or any other discrimination. Upon ratifying the International Covenant on Economic, Social and Cultural Rights States must provide free primary education within two years.
• Secondary (or Elementary, Technical and Professional in the UDHR) Education must be generally available and accessible.
• At the University Level, Education should be provided according to capacity. That is, anyone who meets the necessary education standards should be able to go to university.

Both secondary and higher education shall be made accessible "by every appropriate means, and in particular by the progressive introduction of free education".

Compulsory education

The realization of the right to education on a national level may be achieved through compulsory education, or more specifically free compulsory primary education, as stated in both the Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights.

Right to education for children

The rights of all children from early childhood stem from the 1948 Universal Declaration of Human Rights. The declaration proclaimed in article 1: ‘All human beings are born free and equal in dignity and rights’. The declaration states that human rights begin at birth and that childhood is a period demanding special care and assistance [art. 25 (2)]. The 1959 Declaration of the Rights of the Child affirmed that: ‘mankind owes to the child the best it has to give’, including education. This was amplified by the International Covenant on Economic, Social and Cultural Rights of 1966 which states that: ‘education shall be directed to the full development of the human personality and the sense of its dignity, and shall strengthen the respect for human rights and fundamental freedoms.

The World Declaration on Education for All (EFA) adopted in 1990 in Jomtien, Thailand, states in article 5 that: ‘Learning begins at birth [...] This calls for early childhood care and initial education.’ A decade later, the Dakar Framework for Action on EFA established six goals, the first of which was: ‘expanding and improving early childhood care and education, especially for the most vulnerable and disadvantaged children.’ Protection of children of all ages from exploitation and actions that would jeopardize their health, education and well-being has also been emphasized by the International Labour Organization in Conventions No. 138 on the Minimum Age of Employment (1973) and No. 182 on the Prohibition and Immediate Action for the Elimination of the Worst Forms of Child Labour (1999). The United Nations contributed to such endeavours by the Declaration of the Rights of the Child unanimously adopted by the General Assembly in 1959.

There are various NGO's working towards the right to education. EClickKart is one of such platforms initiated by Rohit N Shetty which states that Education is the basic right and EClickKart is working towards it.

The impact of privatization on the right to education

The privatization of education can have a positive impact for some social groups, in the form of increased availability of learning opportunities, greater parental choice and a wider range of curricula. However, it can also have negative effects resulting from insufficient or inadequate monitoring and regulation by the public authorities (schools without licences, hiring of untrained teachers and absence of quality assurance), with potential risks for social cohesion and solidarity. Of particular concern: "Marginalised groups fail to enjoy the bulk of positive impacts and also bear the disproportionate burden of the negative impacts of privatisation." Furthermore, uncontrolled fees demanded by private providers could undermine universal access to education. More generally, this could have a negative impact on the enjoyment of the right to a good quality education and on the realization of equal educational opportunities.

Supplemental private tutoring, or ‘shadow education’, which represents one specific dimension of the privatization of education, is also growing worldwide. Often a symptom of badly functioning school systems, private tutoring, much like other manifestations of private education, can have both positive and negative effects for learners and their teachers. On one hand, teaching can be tailored to the needs of slower learners and teachers can supplement their school salaries. On the other hand, fees for private tutoring may represent a sizeable share of household income, particularly among the poor, and can therefore create inequalities in learning opportunities. And the fact that some teachers may put more effort into private tutoring and neglect their regular duties can adversely affect the quality of teaching and learning at school. The growth of shadow education, the financial resources mobilized by individuals and families, and the concerns regarding possible teacher misconduct and corruption are leading some ministries of education to attempt to regulate the phenomenon.

Universal access to education

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Universal_access_to_education 

Universal access to education is the ability of all people to have equal opportunity in education, regardless of their social class, race, gender, sexuality, ethnic background or physical and mental disabilities. The term is used both in college admission for the middle and lower classes, and in assistive technology for the disabled. Some critics feel that this practice in higher education, as opposed to a strict meritocracy, causes lower academic standards. In order to facilitate the access of education to all, countries have right to education.

Universal access to education encourages a variety of pedagogical approaches to accomplish the dissemination of knowledge across the diversity of social, cultural, economic, national and biological backgrounds. Initially developed with the theme of equal opportunity access and inclusion of students with learning or physical and mental disabilities, the themes governing universal access to education have now expanded across all forms of ability and diversity. However, as the definition of diversity is within itself is a broad amalgamation, teachers exercising universal access will continually face challenges and incorporate adjustments in their lesson plan to foster themes of equal opportunity of education.

As universal access continues to be incorporated into the U.S. education system, professors and instructors at the college level are required (in some instances by law) to rethink methods of facilitating universal access in their classrooms. Universal access to college education may involve the provision of a variety of different assessment methods of learning and retention. For example, in order to determine how much of the material was learned, a professor may enlist multiple methods of assessment. Methods of assessment may include a comprehensive exam, unit exams, portfolios, research papers, literature reviews, an oral exam or homework assignments. Providing a variety of ways to assess the extent of learning and retention will not only identify the gaps in universal access but may also elucidate the ways to improve universal access.

Non-discrimination and equality in education

Examples of marginalized groups

Human rights are universal rights, therefore it applies to everyone equally and without discrimination. However, a significant number of individuals miss out on education due to discrimination preventing access to education.

Discrimination occurs most obviously in terms of accessing education. For example, girls can face gender-based barriers such as child marriage, pregnancy, and gender-based violence which often prevent them from going to school or contribute to them dropping-out of school. People with disabilities often face literal accessibility issues, such as a lack of ramps or appropriate school transportation, making it difficult to get to school. Migrants often face administrative barriers that prevent them from enrolling, effectively barring them from education systems.

However, discrimination also occurs within education systems when certain groups receiving an inferior quality of education compared with others, for instance, the quality of education in urban schools tends to be higher than that found in rural areas.

Discrimination also happens after education where different groups of people are not able to draw the same benefits from their schooling. For example, educated boys tend to leave school with higher wage potential than equally educated girls.

Non-discrimination and equality provisions found in international human rights law (IHRL) exist to ensure that the principle that human rights are universal is applied in practice. Non-discrimination and equality are not abstract concepts under international human rights law (IHRL). They are elaborated human rights that have been developed over decades to address the discrimination that people face on a day-to-basis. Particularly education where the rights to non-discrimination and equality have been applied to the right to education across numerous human rights treaties, including one dedicated to the issue, known as UNESCO CADE.

Despite the strength of non-discrimination and equality law, eliminating discrimination and inequalities is a challenge that individual states and the international community face. This was acknowledged in 2015 when the international community vowed to ‘leave no one behind’.

International and regional human rights treaties apply the rights to non-discrimination and equality to the right to education of specific marginalised groups. Marginalised groups are those who have suffered prolonged and historical discrimination, usually, but not exclusively, on the basis of identity (gender, for example), characteristics (ethnicity, race), or circumstance (refugees, migrants, internally displaced persons). Marginalisation are very likely to be subject to multiple, compound, or intersectional forms of discrimination.

Examples of marginalised groups include:

• girls and women
• national, ethnic, and linguistic minorities
• people with disabilities
• indigenous people

• migrants
• refugees
• asylum-seekers
• stateless persons
• internally displaced persons (IDPs)
• persons in detention / persons deprived of liberty
• people living in poverty
• people living in rural areas
• people affected by HIV
• people affected by albinism
• LGBTQI
• older people and others

Access to education by law

In 2009 the House of Indian Parliament and the President of India both signed and approved a bill that would grant free law mandated education for children ages six to fourteen. It was a great step towards universal education for all. Muchkund Dubey author of the article “The Right of Children to Free and Compulsory Education Act, 2009 : The Story of Missed Opportunity" discusses and highlights the issues of access, quality of education, financial implication, and discrimination.

In the United States, Brown vs. Board of Education was a landmark decision because it found and declared that, “separate educational facilities are inherently unequal”. This began the process of desegregation in many schools that had not desegregated yet. The significance of Brown vs. Board was the universal right of all students to attend educational institutions equally rather than separately based on their race. Jonathan Kozol, author of The Shame of the Nation, talks about how “physical conditions in these newly integrated schools were generally more cheerful…state of mind among the teachers and the children [was] more high-spirited” in the aftermath of desegregation.

Universal access

Universal Access to education means people have equal opportunities to take part in any educational system. However, not all individuals, groups, or ethnic groups are given equal access. The United States is credited with the current idea of universal access as a concern for handicapped persons. Two international agencies (World Health Organization and World Bank) estimated that around one billion people all over the world various types of disabilities. Between 93 and 150 million of them are children. Plan International revealed that these kids will not possibly attend school and if ever they enroll will be separated from normal pupils. The Global Partnership for Education said approximately 90 percent of children afflicted by disabilities from low and middle income nations are not studying. Historically, these kids are not included in the ordinary education system and referred to special learning schools.

It is unfortunate that education up to this very day is not accessible to millions of schoolchildren globally. 72 million or more children of primary education age do not go to school. Some 759 million adults are uneducated. They do not have the knowledge needed in improving their families’ living conditions. Poverty leads to lack of education. In almost all countries (developing and developed), children are denied education as a result of inequalities that emanate from health, gender, and cultural identity like religion, language, and ethnic origin. Factors associated with poverty including unemployment, illiterate parents, and ailments increase the possibility of non-schooling, and dropout rates. Universal primary education has turned out as a major problem for many nations. Majority of these developing states do not possess sufficient financial resources to build schools, provide books and other materials, and recruit, train, and pay teachers. The Sub-Saharan African region is the most affected region as 32 million African children are still uneducated. This is followed by Central and East Asia as well as the Pacific with 27 million or more. However, observers noted that universal access to education remains an attainable goal by 2030.

Bibliography

• The Big Test - a history of the twentieth century development in the United States of universal access to colleges.

Beta blocker

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Beta_blocker 

 

Beta blockers
Skeletal formula of propranolol, the first clinically successful beta blocker
Class identifiers
Synonyms	beta-blockers, β-blockers, beta-adrenergic blocking agents, beta antagonists, beta-adrenergic antagonists, beta-adrenoreceptor antagonists, beta adrenergic receptor antagonists, BB
Use	Hypertension, arrhythmia, etc.
ATC code	C07
Biological target	beta receptors
Clinical data
Drugs.com	Drug Classes
Consumer Reports	Best Buy Drugs
WebMD	MedicineNet  RxList
External links
MeSH	D000319

Beta blockers (beta-blockers, β-blockers, etc.) are a class of medications that are predominantly used to manage abnormal heart rhythms, and to protect the heart from a second heart attack (myocardial infarction) after a first heart attack (secondary prevention). They are also widely used to treat high blood pressure (hypertension), although they are no longer the first choice for initial treatment of most patients.

Beta blockers are competitive antagonists that block the receptor sites for the endogenous catecholamines epinephrine (adrenaline) and norepinephrine (noradrenaline) on adrenergic beta receptors, of the sympathetic nervous system, which mediates the fight-or-flight response. Some block activation of all types of β-adrenergic receptors and others are selective for one of the three known types of beta receptors, designated β₁, β₂ and β₃ receptors. β₁-adrenergic receptors are located mainly in the heart and in the kidneys. β₂-adrenergic receptors are located mainly in the lungs, gastrointestinal tract, liver, uterus, vascular smooth muscle, and skeletal muscle. β₃-adrenergic receptors are located in fat cells.

Beta receptors are found on cells of the heart muscles, smooth muscles, airways, arteries, kidneys, and other tissues that are part of the sympathetic nervous system and lead to stress responses, especially when they are stimulated by epinephrine (adrenaline). Beta-blockers interfere with the binding to the receptor of epinephrine and other stress hormones and weaken the effects of stress hormones.

In 1964, James Black synthesized the first clinically significant beta blockers—propranolol and pronethalol; it revolutionized the medical management of angina pectoris and is considered by many to be one of the most important contributions to clinical medicine and pharmacology of the 20th century.

For the treatment of primary hypertension, meta-analyses of studies which mostly used atenolol have shown that although beta blockers are more effective than placebo in preventing stroke and total cardiovascular events, they are not as effective as diuretics, medications inhibiting the renin–angiotensin system (e.g., ACE inhibitors), or calcium channel blockers.

Medical uses

Large differences exist in the pharmacology of agents within the class, thus not all beta-blockers are used for all indications listed below.

Indications for beta-blockers include:

• Angina pectoris
• Atrial fibrillation
• Cardiac arrhythmia
• Congestive heart failure
• Essential tremor
• Glaucoma (as eye drops, they decrease intraocular pressure by lowering aqueous humor secretion.)
• Hypertension, although they are generally not preferred as an initial treatment.
• Hyperthyroidism
• Migraine prophylaxis
• Mitral valve prolapse
• Myocardial infarction
• Phaeochromocytoma, in conjunction with α-blocker
• Postural orthostatic tachycardia syndrome
• Symptomatic control (tachycardia, tremor) in anxiety and hyperthyroidism
• Theophylline overdose

Beta-blockers have also been used for:

• Acute aortic dissection
• Hypertrophic obstructive cardiomyopathy
• Long QT syndrome
• Marfan syndrome (treatment with propranolol slows progression of aortic dilation and its complications)
• Prevention of variceal bleeding in portal hypertension
• Possible mitigation of hyperhidrosis
• Social and other anxiety disorders
• Controversially, for reduction of perioperative mortality in non-cardiac surgery, but the best evidence suggests that they increase mortality when used this way

Congestive heart failure

Although beta blockers were once contraindicated in congestive heart failure, as they have the potential to worsen the condition due to their effect of decreasing cardiac contractility, studies in the late 1990s showed their efficacy at reducing morbidity and mortality. Bisoprolol, carvedilol, and sustained-release metoprolol are specifically indicated as adjuncts to standard ACE inhibitor and diuretic therapy in congestive heart failure, although at doses typically much lower than those indicated for other conditions. Beta-blockers are only indicated in cases of compensated, stable congestive heart failure; in cases of acute decompensated heart failure, beta-blockers will cause a further decrease in ejection fraction, worsening the patient's current symptoms.

Beta-blockers are known primarily for their reductive effect on heart rate, although this is not the only mechanism of action of importance in congestive heart failure. Beta-blockers, in addition to their sympatholytic β1 activity in the heart, influence the renin–angiotensin system at the kidneys. Beta-blockers cause a decrease in renin secretion, which in turn reduces the heart oxygen demand by lowering the extracellular volume and increasing the oxygen-carrying capacity of the blood. Heart failure characteristically involves increased catecholamine activity on the heart, which is responsible for several deleterious effects, including increased oxygen demand, propagation of inflammatory mediators, and abnormal cardiac tissue remodeling, all of which decrease the efficiency of cardiac contraction and contribute to the low ejection fraction. Beta-blockers counter this inappropriately high sympathetic activity, eventually leading to an improved ejection fraction, despite an initial reduction in ejection fraction.

Trials have shown beta blockers reduce the absolute risk of death by 4.5% over a 13-month period. In addition to reducing the risk of mortality, the numbers of hospital visits and hospitalizations were also reduced in the trials.

Therapeutic administration of beta-blockers for congestive heart failure ought to begin at very low doses (1/8 of target) with a gradual escalation of the dose. The heart of the patient must adjust to decreasing stimulation by catecholamines and find a new equilibrium at a lower adrenergic drive.

Anxiety

Officially, beta blockers are not approved for anxiolytic use by the U.S. Food and Drug Administration. However, many controlled trials in the past 25 years indicate beta blockers are effective in anxiety disorders, though the mechanism of action is not known. The physiological symptoms of the fight-or-flight response (pounding heart, cold/clammy hands, increased respiration, sweating, etc.) are significantly reduced, thus enabling anxious individuals to concentrate on the task at hand.

Musicians, public speakers, actors, and professional dancers have been known to use beta-blockers to avoid performance anxiety, stage fright, and tremor during both auditions and public performances. The application to stage fright was first recognized in The Lancet in 1976, and by 1987, a survey conducted by the International Conference of Symphony Orchestra Musicians, representing the 51 largest orchestras in the United States, revealed 27% of its musicians had used beta-blockers and 70% obtained them from friends, not physicians. Beta-blockers are inexpensive, said to be relatively safe, and on one hand, seem to improve musicians' performances on a technical level, while some, such as Barry Green, the author of "The Inner Game of Music" and Don Greene, a former Olympic diving coach who teaches Juilliard students to overcome their stage fright naturally, say the performances may be perceived as "soulless and inauthentic".

Cardiac surgery

The use of beta blockers around the time of cardiac surgery decreases the risk of heart dysrhythmias. Starting them around the time of other types of surgery, however, may worsen outcomes.

Performance-enhancing use

Because they promote lower heart rates and reduce tremors, beta blockers have been used in professional sports where high accuracy is required, including archery, shooting, golf and snooker. Beta blockers are banned by the International Olympic Committee. In the 2008 Summer Olympics, 50-metre pistol silver medalist and 10-metre air pistol bronze medalist Kim Jong-su tested positive for propranolol and was stripped of his medals.

For similar reasons, beta blockers have also been used by surgeons.

Classical musicians have commonly used beta blockers since the 1970's to reduce stage fright.

Adverse effects

Adverse drug reactions associated with the use of beta blockers include: nausea, diarrhea, bronchospasm, dyspnea, cold extremities, exacerbation of Raynaud's syndrome, bradycardia, hypotension, heart failure, heart block, fatigue, dizziness, alopecia (hair loss), abnormal vision, hallucinations, insomnia, nightmares, sexual dysfunction, erectile dysfunction and/or alteration of glucose and lipid metabolism. Mixed α₁/β-antagonist therapy is also commonly associated with orthostatic hypotension. Carvedilol therapy is commonly associated with edema. Due to the high penetration across the blood–brain barrier, lipophilic beta blockers, such as propranolol and metoprolol, are more likely than other less lipophilic beta blockers to cause sleep disturbances, such as insomnia, vivid dreams and nightmares.

Adverse effects associated with β₂-adrenergic receptor antagonist activity (bronchospasm, peripheral vasoconstriction, alteration of glucose and lipid metabolism) are less common with β₁-selective (often termed "cardioselective") agents, but receptor selectivity diminishes at higher doses. Beta blockade, especially of the beta-1 receptor at the macula densa, inhibits renin release, thus decreasing the release of aldosterone. This causes hyponatremia and hyperkalemia.

Hypoglycemia can occur with beta blockade because β2-adrenoceptors normally stimulate glycogen breakdown (glycogenolysis) in the liver and pancreatic release of the hormone glucagon, which work together to increase plasma glucose. Therefore, blocking β2-adrenoceptors lowers plasma glucose. β1-blockers have fewer metabolic side effects in diabetic patients; however, the fast heart rate that serves as a warning sign for insulin-induced low blood sugar may be masked, resulting in hypoglycemia unawareness. This is termed beta blocker-induced hypoglycemia unawareness. Therefore, beta blockers are to be used cautiously in diabetics.

A 2007 study revealed diuretics and beta blockers used for hypertension increase a patient's risk of developing diabetes mellitus, while ACE inhibitors and angiotensin II receptor antagonists (angiotensin receptor blockers) actually decrease the risk of diabetes. Clinical guidelines in Great Britain, but not in the United States, call for avoiding diuretics and beta blockers as first-line treatment of hypertension due to the risk of diabetes.

Beta blockers must not be used in the treatment of selective alpha-adrenergic agonist overdose. The blockade of only beta receptors increases blood pressure, reduces coronary blood flow, left ventricular function, and cardiac output and tissue perfusion by means of leaving the alpha-adrenergic system stimulation unopposed. Beta blockers with lipophilic properties and CNS penetration such as metoprolol and labetalol may be useful for treating CNS and cardiovascular toxicity from a methamphetamine overdose. The mixed alpha- and beta blocker labetalol is especially useful for treatment of concomitant tachycardia and hypertension induced by methamphetamine. The phenomenon of "unopposed alpha stimulation" has not been reported with the use of beta blockers for treatment of methamphetamine toxicity. Other appropriate antihypertensive drugs to administer during hypertensive crisis resulting from stimulant overdose are vasodilators such as nitroglycerin, diuretics such as furosemide, and alpha blockers such as phentolamine.

Contraindications

Contraindications for beta-blockers include:

• Abrupt discontinuations
• Acute bronchospasm
• Acute heart failure
• Asthma
• AV block
• Bradycardia
• Bronchitis
• Cardiogenic shock
• Cerebrovascular disease
• Chronic obstructive pulmonary disease (COPD)
• Diabetes mellitus
• Emphysema
• Hypersensitivity to beta blockers
• Hypotension
• Kidney failure
• Hepatic disease
• Myopathy
• Pheochromocytoma
• Psoriasis
• Stroke
• Vasospastic angina
• Wolff–Parkinson–White syndrome

Asthma

The 2007 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines recommend against the use of non-selective beta blockers in asthmatics, while allowing for the use of cardioselective beta blockers. Cardioselective beta-blocker (β1 blockers), if really required, can be prescribed at the least possible dose to those with mild to moderate respiratory symptoms. β2-agonists can somewhat mitigate β-Blocker-induced bronchospasm where it exerts greater efficacy on reversing selective β-blocker-induced bronchospasm than the nonselective β-blocker-induced worsening asthma and/or COPD.

Diabetes mellitus

Epinephrine signals early warning of the upcoming hypoglycemia.

Beta-blockers' inhibition on epinephrine's effect can somewhat exacerbate hypoglycemia by interfering with glycogenesis and mask signs of hypoglycemia such as tachycardia, palpitations, diaphoresis, and tremors. Diligent blood glucose level monitoring is necessary for a patient with diabetes mellitus on beta-blocker.

Hyperthyroidism

Abrupt withdrawal can result in a thyroid storm.

Bradycardia or AV block

Unless a pacemaker is present, beta-blockers can severely depress conduction in the AV node, resulting in a reduction of heart rate and cardiac output. Usage of beta-blockers in tachycardic patients with Wolff-Parkinson-White Syndrome can result in severe bradycardia, necessitating treatment with a pacemaker.

Toxicity

Glucagon, used in the treatment of overdose, increases the strength of heart contractions, increases intracellular cAMP, and decreases renal vascular resistance. It is, therefore, useful in patients with beta blocker cardiotoxicity. Cardiac pacing is usually reserved for patients unresponsive to pharmacological therapy.

People experiencing bronchospasm due to the β₂ receptor-blocking effects of nonselective beta blockers may be treated with anticholinergic drugs, such as ipratropium, which are safer than beta agonists in patients with cardiovascular disease. Other antidotes for beta blocker poisoning are salbutamol and isoprenaline.

β-receptor antagonism

Stimulation of β₁ receptors by epinephrine and norepinephrine induces a positive chronotropic and inotropic effect on the heart and increases cardiac conduction velocity and automaticity. Stimulation of β₁ receptors on the kidney causes renin release. Stimulation of β₂ receptors induces smooth muscle relaxation, induces tremor in skeletal muscle, and increases glycogenolysis in the liver and skeletal muscle. Stimulation of β₃ receptors induces lipolysis.

Beta blockers inhibit these normal epinephrine- and norepinephrine-mediated sympathetic actions, but have minimal effect on resting subjects. That is, they reduce the effect of excitement or physical exertion on heart rate and force of contraction, and also tremor, and breakdown of glycogen. Beta blockers can have a constricting effect on the bronchi of the lungs, possibly worsening or causing asthma symptoms.

Since β₂ adrenergic receptors can cause vascular smooth muscle dilation, beta blockers may cause some vasoconstriction. However, this effect tends to be small because the activity of β₂ receptors is overshadowed by the more dominant vasoconstricting α₁ receptors. By far the greatest effect of beta blockers remains in the heart. Newer, third-generation beta blockers can cause vasodilation through blockade of alpha-adrenergic receptors.

Accordingly, nonselective beta blockers are expected to have antihypertensive effects. The primary antihypertensive mechanism of beta blockers is unclear, but may involve reduction in cardiac output (due to negative chronotropic and inotropic effects). It may also be due to reduction in renin release from the kidneys, and a central nervous system effect to reduce sympathetic activity (for those beta blockers that do cross the blood–brain barrier, e.g. propranolol).

Antianginal effects result from negative chronotropic and inotropic effects, which decrease cardiac workload and oxygen demand. Negative chronotropic properties of beta-blockers allow the lifesaving property of heart rate control. Beta-blockers are readily titrated to optimal rate control in many pathologic states.

The antiarrhythmic effects of beta blockers arise from sympathetic nervous system blockade—resulting in depression of sinus node function and atrioventricular node conduction, and prolonged atrial refractory periods. Sotalol, in particular, has additional antiarrhythmic properties and prolongs action potential duration through potassium channel blockade.

Blockade of the sympathetic nervous system on renin release leads to reduced aldosterone via the renin–angiotensin–aldosterone system, with a resultant decrease in blood pressure due to decreased sodium and water retention.

Intrinsic sympathomimetic activity

Also referred to as intrinsic sympathomimetic effect, this term is used particularly with beta-blockers that can show both agonism and antagonism at a given beta receptor, depending on the concentration of the agent (beta-blocker) and the concentration of the antagonized agent (usually an endogenous compound, such as norepinephrine). See partial agonist for a more general description.

Some beta blockers (e.g. oxprenolol, pindolol, penbutolol, labetalol and acebutolol) exhibit intrinsic sympathomimetic activity (ISA). These agents are capable of exerting low-level agonist activity at the β-adrenergic receptor while simultaneously acting as a receptor site antagonist. These agents, therefore, may be useful in individuals exhibiting excessive bradycardia with sustained beta blocker therapy.

Agents with ISA are not used after myocardial infarctions, as they have not been demonstrated to be beneficial. They may also be less effective than other beta-blockers in the management of angina and tachyarrhythmia.

α₁-receptor antagonism

Some beta blockers (e.g., labetalol and carvedilol) exhibit mixed antagonism of both β- and α₁-adrenergic receptors, which provides additional arteriolar vasodilating action.

Examples

Dichloroisoprenaline, the first beta blocker

Nonselective agents

Nonselective beta blockers display both β₁ and β₂ antagonism.

• Propranolol
• Bucindolol (has additional α₁-blocking activity)
• Carteolol
• Carvedilol (has additional α₁-blocking activity)
• Labetalol (has additional α₁-blocking activity)
• Nadolol^[74]
• Oxprenolol (has intrinsic sympathomimetic activity)
• Penbutolol (has intrinsic sympathomimetic activity)
• Pindolol (has intrinsic sympathomimetic activity)
• Sotalol (not considered a "typical beta blocker")
• Timolol

β₁-selective agents

β₁-selective beta blockers are also known as cardioselective beta blockers.

• Acebutolol (has intrinsic sympathomimetic activity, ISA)
• Atenolol
• Betaxolol
• Bisoprolol
• Celiprolol (has intrinsic sympathomimetic activity)
• Metoprolol
• Nebivolol
• Esmolol

β₂-selective agents

• Butaxamine
• ICI-118,551

β₃-selective agents

• SR 59230A

β₁ selective antagonist and β₃ agonist agents

• Nebivolol

Comparative information

Pharmacological differences

• Agents with intrinsic sympathomimetic action (ISA)
  • Acebutolol, pindolol, labetalol, mepindolol, oxprenolol, celiprolol, penbutolol
• Agents organized by lipid solubility (lipophilicity)
  • High lipophilicity: propranolol, labetalol
  • Intermediate lipophilicity: metoprolol, bisoprolol, carvedilol, acebutolol, timolol, pindolol
  • Low lipophilicity (also known as hydrophilic beta-blockers): atenolol, nadolol, and sotalol
• Agents with membrane stabilizing effect
  • Carvedilol, propranolol > oxprenolol > labetalol, metoprolol, timolol

Indication differences

• Agents specifically labeled for cardiac arrhythmia
  • Esmolol, sotalol, landiolol (Japan)
• Agents specifically labeled for congestive heart failure
  • Bisoprolol, carvedilol, sustained-release metoprolol
• Agents specifically labeled for glaucoma
  • Betaxolol, carteolol, levobunolol, timolol, metipranolol
• Agents specifically labeled for myocardial infarction
  • Atenolol, metoprolol (immediate release), propranolol (immediate release), timolol, carvedilol (after left ventricular dysfunction), bisoprolol (preventive treatment before and primary treatment after heart attacks)
• Agents specifically labeled for migraine prophylaxis
  • Timolol, propranolol

Propranolol is the only agent indicated for the control of tremor, portal hypertension, and esophageal variceal bleeding, and used in conjunction with α-blocker therapy in phaeochromocytoma.

Other effects

Beta blockers, due to their antagonism at beta-1 adrenergic receptors, inhibit both the synthesis of new melatonin and its secretion by the pineal gland. The neuropsychiatric side effects of some beta blockers (e.g. sleep disruption, insomnia) may be due to this effect.

Some pre-clinical and clinical research suggests that some beta blockers may be beneficial for cancer treatment. However, other studies do not show a correlation between cancer survival and beta blocker usage. Also, a 2017 meta-analysis failed to show any benefit for the use of beta blockers in breast cancer.

Beta blockers have also been used for the treatment of schizoid personality disorder. However, there is limited evidence supporting the efficacy of supplemental beta-blocker use in addition to antipsychotic drugs for treating schizophrenia.

Contrast media are not contraindicated in patients receiving beta blockers.