Beta-blockers in hypertension

Beta-blockers are no longer recommended as first-line drugs in the treatment of hypertension (1).

• beta-blockers are not a preferred initial therapy for hypertension (1) - they are an option in Step 4 of the NICE hypertension management guidance

Other indications for the use of beta-blockers in hypertension include (2):

• compelling indication - myocardial infarction, angina
• possible indication - heart failure*

Contraindications for the use of beta-blockers in hypertension include (2):

• possible contraindication - heart failure*, dyslipidaemia, peripheral vascular disease ***
• compelling contraindications - asthma or COPD**, heart block

* beta-blockers may worsen heart failure - however in specialist hands beta-blocker are a treatment option for heart failure

** there is evidence that, in patients with COPD, cardioselective beta blockers do not change FEV1 or increase respiratory symptoms (2)

Notes:

• there is evidence that in patients with essential hypertension, a beta-blocker (in this case atenolol) is not better than placebo or no treatment for reducing cardiovascular morbidity or all cause mortality. However, when compared to other antihypertensive drugs, it may increase the risk of stroke or death (4,5)
• in patients with raised blood pressure and symptomatic angina, a beta blocker is the preferred treatment of choice (6)
• a meta-analysis has revealed that beta-blockers should not be considered first-line therapy for older hypertensive patients without another indication for these agents; however, in younger patients beta-blockers are associated with a significant reduction in cardiovascular morbidity and mortality (7)
• a systematic review concluded that " available evidence does not support the use of beta-blockers as first-line drugs in the treatment of hypertension. This conclusion is based on the relatively weak effect of beta-blockers to reduce stroke and the absence of an effect on coronary heart disease when compared to placebo or no treatment. More importantly, it is based on the trend towards worse outcomes in comparison with calcium-channel blockers, renin-angiotensin system inhibitors, and thiazide diuretics. Most of the evidence for these conclusions comes from trials where atenolol was the beta-blocker used (75% of beta-blocker participants in this review). However, it is not known at present whether beta-blockers have differential effects on younger and elderly patients or whether there are differences between the different sub-types of beta-blockers." (8)
• beta blockers and development of diabetes (9)
  • in patients with hypertension, first-line therapy with beta-blockers is asociated with an increased risk of development of diabetes - however this meta-analysis revealed that beta-blocker did not affect risk of death or myocardial infarction compared with ACE inhibitors, angiotensin receptor blockers, or calcium channel blockers

Reference:

• (1) NICE (November 2016). Management of hypertension in adults in primary care.
• (2) BMJ (1999); 319: 630-5.
• (3) Salpeter S et al. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2005;(4):CD003566.
• (4) Carlberg B et al. Atenolol in hypertension: is it a wise choice? Lancet 2004; 364:1684-9
• (5) Lindholm LH et al. Shold beta blockers remain the first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005;366:1545-53.
• (6) JBS2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 (Supp 5).
• (7) Khan N, McAlister FA. Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis. CMAJ. 2006 Jun 6;174(12):1737-4
• (8) Wiysonge C et al. Beta-blockers for hypertension. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD002003
• (9) Bangalore S et al. A meta-analysis of 94,492 patients with hypertension treated with beta blockers to determine the risk of new-onset diabetes mellitus.Am J Cardiol. 2007 Oct 15;100(8):1254-62