Setting: Tertiary care Veterans Affairs medical center. Patient: A 52-year-old man with a C6 American Spinal Injury Association class B spinal cord injury (SCI). Case Description: The patient transferred from another hospital to our rehabilitation unit. He was well known to the rehabilitation team and had a history of autonomic dysreflexia usually secondary to bowel or bladder issues, but no hypertension. At admission, he was noted to be on 50mg of metoprolol twice a day with blood pressure significantly higher than his baseline. His indwelling urinary catheter was patent and his bowel program was effective. He had a stage III pressure ulcer. An extensive work-up revealed no causes for autonomic dysreflexia. His elevated blood pressure was treated with a calcium channel blocker, which was minimally effective with pressures as high as 190/93. Assessment/Results: The metoprolol was discontinued and the following day his blood pressure began to normalize. Within 3 days, blood pressure was within a desirable range without pharmacologic management. Discussion: This is the first reported case, to our knowledge, of a β-blocker exacerbating hypertension in an SCI patient prone to autonomic dysreflexia. It is stated in DeLisa's Rehabilitation Medicine, 3rd edition, that β-blockers are to be avoided in autonomic dysreflexia because of the potential adverse effects of unopposed peripheral alpha stimulation. A physiologic possibility exists that, in a hyperadrenergic state, a β-blocker would cause unopposed alpha-receptor stimulation with subsequent peripheral vasoconstriction and elevated blood pressure. A study of rats with autonomic dysreflexia has demonstrated blood pressure elevations with the use of propanolol. Conclusion: β-blockade in autonomic dysreflexia may allow for unopposed alpha stimulation and subsequent exacerbation of hypertension.