Beta-blockers less effective for hypertension than other agents

A meta-analysis of 20 studies found beta-blockers should not be the first choice for treatment of hypertension.

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 doctor’s supervision in a slow and gradual manner.”

Stroke risk reduction

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% (P<.0001).

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 atenolol.

Lars Hjalmar Lindholm, MD [photo]
Lars Hjalmar Lindholm, MD

“We don’t 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 said.

Franz Messerli, MD, director of the hypertension program at St. Luke’s—Roosevelt Hospital, said he is shocked that many physicians have not yet realized that beta-blockers are ineffective for hypertension.

“It is just amazing to me that after we clearly documented the lack of efficacy of beta-blockers in the [1998] 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 I’ve said before, this demands a change in the guidelines,” Messerli said. – by Jeremy Moore

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.

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 doctor’s supervision in a slow and gradual manner.”

Stroke risk reduction

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% (P<.0001).

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 atenolol.

Lars Hjalmar Lindholm, MD [photo]
Lars Hjalmar Lindholm, MD

“We don’t 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 said.

Franz Messerli, MD, director of the hypertension program at St. Luke’s—Roosevelt Hospital, said he is shocked that many physicians have not yet realized that beta-blockers are ineffective for hypertension.

“It is just amazing to me that after we clearly documented the lack of efficacy of beta-blockers in the [1998] 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 I’ve said before, this demands a change in the guidelines,” Messerli said. – by Jeremy Moore

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.