Beta-blockers should not be used as a first-line choice for
hypertension treatment, according to a recently published meta-analysis.
We should be using diuretics, ACE inhibitors or calcium
channel blockers. Beta-blockers should be downgraded to about the fourth or
fifth choice in treating hypertension, Lars Hjalmar Lindholm, MD,
chairman of the department of public health and clinical medicine at the
University Hospital in Umea, Sweden, told Cardiology Today.
Lindholm was the corresponding author on the meta-analysis in
Lancet of 20 beta-blocker trials with a total of 133,384 patients;
13 trials compared beta-blockers with other antihypertensive drugs and seven
compared beta-blockers to placebo.
Beta-blockers remain an excellent treatment for post-MI, heart
failure or proarrhythmia, but not for first-line hypertensive treatment,
Lindholm said. Patients should never stop treatment with beta-blockers
rapidly. It should always be done under a doctors supervision in a slow
and gradual manner.
In the studies that compared beta-blockers to placebo, there was a
19% reduction in stroke risk for all beta-blockers. In the trials that compared
beta-blockers with other drugs, the relative risk of stroke was 16% higher with
beta-blocker treatment (P=.009). This was primarily driven by treatment
with atenolol, where the relative increased risk was 26%
The effect of other beta-blockers on stroke was not significant
(P=.13); there were only 77 strokes in the trials that did not use
Lars Hjalmar Lindholm,
We dont know why beta-blockers have this effect on
stroke, but it is a constant finding, Lindholm said.
There was a trend in the meta-analysis toward increased mortality
with beta-blockers (3%, P=.14) and no difference in MI.
This was not surprising because blood pressure has never
been strongly linked to myocardial infarction. Risk factors like lipids,
smoking and insulin levels are much more closely linked, Lindholm
Franz Messerli, MD, director of the hypertension program at
St. LukesRoosevelt Hospital, said he is shocked that many
physicians have not yet realized that beta-blockers are ineffective for
It is just amazing to me that after we clearly documented
the lack of efficacy of beta-blockers in the  JAMA paper,
which showed that despite lowering blood pressure the agent did not reduce MI
or stroke, it took another seven years to re-emphasize the same findings,
he told Today in Cardiology.
During this time, millions of patients were exposed to the
cost, inconvenience and side effects of beta-blockers without having any
benefit. Conceivably, some of the newer beta-blockers, such as carvedilol
(Coreg, GlaxoSmithKline) may have a more hypertension-friendly hemodynamic
profile than the traditional agents. Clearly, as Ive said before, this
demands a change in the guidelines, Messerli said. by Jeremy
For more information:
- Lindholm LH, Carlberg B, Samuelsson O. Should beta-blockers
remain first choice in the treatment of primary hypertension? A meta-analysis.
Lancet. Online publication. Oct. 18, 2005.
- Messerli FH, Grossman E, Goldbourt, U. Are beta-blockers
efficacious as first-line therapy for hypertension in the elderly?: a
systematic review. JAMA. 1998;279:1903-1907.