The quote was based on a metaanalysis by Lindholm et al., who concluded that beta-blockers should not remain first choice in the treatment of primary hypertension and should not be used as reference drugs in future randomized controlled trials (RCTs) of hypertension (1). Unfortunately, many experts in the field have endorsed the conclusions of this faulty metaanalysis. Beta-blockers have been used for more than 35 yr for the treatment of hypertension. The controversy regarding their continued use is of paramount importance, particularly because there are more than 1 billion hypertensive individuals who require treatment, and only four classes of antihypertensive agents are available: beta-blockers, diuretics, calcium antagonists, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). The two other drug classes (alpha blockers [doxazosin] and centrally acting agents [methyldopa, clonidine]) have been rendered relatively obsolete for the management of primary hypertension (see later discussion and alpha-blocker section in Chapter 8). Methyl dopa remains useful mainly for hypertension in pregnancy.
In 14 studies analyzed by Lindholm et al., atenolol was the beta-blocker used; in four trials, mixtures of atenolol, metoprolol, and pindolol were used (see Table 9-1).
In a Lancet letter, Cruickshank stated that by lumping together all randomized hypertension trials involving beta-blockers, Lars Lindholm and colleagues have arrived at misleading conclusions (2), and I concur with this statement. This discussion reviews trials selected by Lindholm and colleagues and emphasizes that the metaanalysis suggests that atenolol is not an effective choice for the management of hypertension but does not indicate that other beta-blockers are ineffective in decreasing cardiovascular disease (CVD) morbidity and mortality associated with hypertension.
KeywordsCalcium Antagonist Coronary Heart Disease Event Primary Hypertension Achieve Goal Blood Pressure Conduit Artery Function Evaluation
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- 5.Yurenev AP, Dyakonova HG, Novikov ID, et al. Management of essential hypertension in patients with different degrees of left ventricular hypertrophy. Multicenter trial. Am J Hypertens 1992; (6 Pt 2): 182S–189S.Google Scholar
- 6.The Dutch TIA Trial Study Group. Trial of secondary prevention with atenolol after transient ischemic attack or nondisabling ischemic stroke. Stroke 1993;24:543–548.Google Scholar
- 8.MRC Working Party. MRC trial of treatment of mild hypertension: Principal results. BMJ 1985;291: 97–104.Google Scholar
- 9.Treatment of hypertension: The 1985 results. Lancet 1985;2:645.Google Scholar
- 11.Khan M Gabriel. Hypertension. In: Cardiac Drug Therapy, 2nd ed. Philadelphia, WB Saunders, 1988, p. 62.Google Scholar
- 16.Pitt B. The role of beta-adrenergic blocking agents in preventing sudden cardiac death. Circulation 1992; 85(1 Suppl):107.Google Scholar
- 24.CAFE investigators for the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) investigators. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: Principal results of the Conduit Artery Function Evaluation (CAFE) Study. Circulation 2006;113:1213–1225.CrossRefGoogle Scholar
- 25.ASCOT: Dahlof B, Sever PS, Poulter NR, et al. for the ASCOT investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): A multicentre randomised controlled trial. Lancet 2005;366: 895–906.PubMedCrossRefGoogle Scholar
- 30.Khan M Gabriel. Which beta blocker to choose. In: Heart Disease Diagnosis and Therapy, a Practical Approach, 2nd ed. Totowa, NJ, Humana Press, 2005, p. 55.Google Scholar
- 40.The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major out-comes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288:2981–2997.CrossRefGoogle Scholar
- 41.UKPDS: UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS. BMJ 1998;317:713–720.Google Scholar
- 50.Wright JT, Bakris G, Greene T, et al. for the African American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: Results from the AASK Trial. JAMA 2002;288:2421–2431.PubMedCrossRefGoogle Scholar
- 53.Khan M Gabriel. Alpha-1 adrenergic blockers. In: Cardiac Drug Therapy, 4th ed. Philadelphia, WB Saunders, 1995, p. 103.Google Scholar
- 54.INSIGHT: Brown MJ, Palmer CR, Castaigne A, et al. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a Goal in Hypertension Treatment (INSIGHT). Lancet 2000;356: 366–372.PubMedCrossRefGoogle Scholar
- 57.Khan M Gabriel. Recommendations for hypertension in young and older patients. In: Cardiac Drug Therapy, 6th ed. Philadelphia, WB Saunders, 2003, pp. 134–143.Google Scholar
- 58.The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003;289:2560–2572.Google Scholar
- 68.Khan M Gabriel. Hypertension trials. In: Cardiac Drug Therapy, 6th ed. Philadelphia, WB Saunders, 2003, p. 505.Google Scholar