SNOWMASS, COLO. – Beta-blockers have lost their decades-long status as first-line therapy for hypertension.
"Generally, I think there is a consensus that beta-blockers are a poor choice for uncomplicated hypertension," Dr. Clive Rosendorff observed at the Annual Cardiovascular Conference at Snowmass.
Dr. Clive Rosendorff
Abundant evidence indicates that beta-blockers provide less protection against stroke, MI, and overall mortality than other classes of antihypertensive agents. They offer less renal protection than ramipril and achieve less regression of left ventricular hypertrophy than other antihypertensive drugs.
Moreover, as was shown in the Conduit Artery Function Evaluation (CAFE) study, beta-blockers have what has been termed "pseudo-antihypertensive efficacy": that is, they fail to reduce central aortic blood pressure to the same extent they lower systolic blood pressure, which may explain why they are less cardioprotective than other antihypertensive drugs. They also are associated with an increase in insulin resistance, reduced exercise tolerance, weight gain, and a high rate of withdrawal because of side effects, said Dr. Rosendorff, professor of medicine at Mount Sinai School of Medicine, New York.
Dr. Rosdendorff chaired the joint American College of Cardiology/American Heart Association/American Society for Hypertension committee that wrote the soon-to-be-released revised scientific statement on the treatment of hypertension in the prevention and management of ischemic heart disease. He also chaired the 2007 AHA scientific statement on the subject (Circulation 2007;115:2761-88).
One of the most persuasive pieces of evidence of the shortcomings of beta-blockers as first-line agents for uncomplicated hypertension to appear since the release of the 2007 AHA scientific statement was a meta-analysis of six meta-analyses. The six meta-analyses incorporated a total of 26 randomized trials of beta-blockers versus placebo. The conclusion: beta-blockers were no better than placebo in preventing MI or mortality, although they did result in a 16%-22% relative reduction in stroke risk (J. Am. Coll. Cardiol. 2007;50:563-72).
This meta-meta-analysis also included three meta-analyses of comparative trials of beta-blockers versus diuretics and three meta-analyses of beta-blockers compared with other drugs. Beta-blockers turned out to be significantly worse than the other antihypertensive agents in terms of the three endpoints of MI, stroke, and mortality.
A caveat: these clinical trials and meta-analyses were nearly all restricted to atenolol and short-acting metoprolol.
"We don’t have any comparable data for newer beta-blockers. Carvedilol has never been looked at from the point of view of outcomes in hypertension. Bisoprolol likewise, and nabivolol, too. It’s possible that the paradigm might be changed quite considerably when we have data to support the use of these newer beta-blockers in the treatment of hypertension," the cardiologist said.
Dr. Rosendorff noted that he wasn’t at liberty to discuss the recommendations of the forthcoming ACC/AHA/ASH scientific statement in advance of its release. He stressed that his comments on the drawbacks of beta-blockers for uncomplicated hypertension represented his own views and not necessarily the panel’s.
Of note, however, is that the recently published report of the Eighth Joint National Committee (JNC 8) doesn’t list beta-blockers among the four classes of antihypertensive medications recommended for the initial treatment of hypertension (JAMA 2014;311:507-20).
Dr. Rosendorff reported having no financial conflicts of interest.