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Other Drugs Outperform ß-Blockers in Uncomplicated Hypertension

Some experts suggest that guidelines recommending ß-blockers as first-line therapy for uncomplicated hypertension should be reconsidered.

ß-blockers have clear benefits in patients with myocardial infarction, angina pectoris, tachyarrhythmias, and heart failure. Although ß-blockers are recommended widely and used widely in the treatment of uncomplicated hypertension, their effectiveness in preventing coronary heart disease in this relatively healthy population has been controversial, and results from several recent studies have suggested that other drugs are superior for this purpose.

In the ASCOT-BPLA trial, published in September 2005, researchers compared the ß-blocker atenolol (with a diuretic added first if needed) with the calcium-channel blocker amlodipine (with an angiotensin-converting–enzyme [ACE] inhibitor added first if needed) in almost 20,000 hypertensive patients with multiple cardiac risk factors but without previous overt coronary heart disease. The primary endpoint, cardiac death and nonfatal MI, occurred less frequently in the amlodipine group; this result failed to reach statistical significance, probably because an unexpectedly large number of patients avoided the endpoint by undergoing revascularization. Most secondary endpoints (e.g., adverse coronary events, cardiovascular mortality, all-cause mortality rate, and stroke) were reduced significantly in the amlodipine group. The results were confounded by a slightly greater mean blood pressure reduction in the amlodipine group. The authors and an editorialist disagreed on whether it was simply the greater blood pressure reduction (as opposed to some other characteristic of the drugs themselves) that was responsible for the better outcomes in the amlodipine-ACE inhibitor group (Journal Watch Oct 21 2005).

A month later, researchers published a meta-analysis of 20 trials in which ß-blockers were compared with other drugs or no treatment in patients with primary hypertension. In 13 comparisons with other drugs, relative risk for stroke was 16% higher with ß-blockers, and no significant differences were seen in all-cause mortality or MI rates. In 7 comparisons with placebo or no treatment, risk for stroke was 19% lower with ß-blockers (about half the reduction in stroke risk seen in other trials in which ß-blockers and diuretics were used), and patients who took ß-blockers showed no significant reductions in MI or all-cause mortality rates (Journal Watch Dec 9 2005).

The authors of these studies and an editorialist suggest that guidelines recommending ß-blockers as first-line therapy for uncomplicated hypertension should be reconsidered. However, regardless of the position of ß-blockers in future hypertension guidelines, these drugs will retain their essential role in the treatment of patients with established heart disease.

— Bruce Soloway, MD

Published in Journal Watch General Medicine December 30, 2005