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Beta-Blockers for Hypertension Not Superior

October 24, 2005

Beta-blockers are not superior to other drugs in preventing heart attacks in people with hypertension, according to investigators in Sweden.

The study by Lars Hjalmar Lindholm, MD, and colleagues at Umea University Hospital and University Hospital in Goteborg, Sweden, was published in The Lancet Early Online Publication on and reported by MedPage Today on 18 October 2005.

The researchers' meta-analysis of data, which included 13 randomized controlled trials of 105,951 patients, revealed that beta-blockers are associated with a 16% higher relative risk of stroke compared with other anti-hypertension drugs.

"In comparison with other antihypertensive drugs, the effect of beta-blockers is less than optimum, with a raised risk of stroke," Lindholm and colleagues wrote. "Hence, we believe that beta-blockers should not remain first choice in the treatment of primary [essential] hypertension and should not be used as reference drugs in future randomized controlled trials of hypertension."

Study Findings

The results of Lindholm et al's study confirmed the results of the previous Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA). ASCOT-BPLA showed that combined treatment with Norvasc (amlodipine) and Aceon (perindopril) reduced major cardiovascular events by 16%, stroke by 23%, cardiovascular mortality by 24% and total mortality by 11%, when compared with treatment using the beta-blocker atenolol, with or without the diuretic bendroflumethiazide, according to MedPage Today.

ASCOT-BPLA was prematurely halted in December 2004, when data revealed a higher event rate in the atenolol arm.

The current study by Lindholm and colleagues compared treatment of primary hypertension with beta-blockers versus other anti-hypertensives and also included seven studies comparing beta-blockers with placebo or no treatment.

Results of the analysis showed that the relative risk of stroke was 16% higher for beta-blockers, compared with other anti-hypertensives, and no differences in myocardial infarction were seen.

When the effect of beta-blockers was compared with the effect of placebo or no treatment, the relative stroke-risk decreased by 19% for all beta-blockers (7-29%)-about half the amount seen in previous hypertension trials. Moreover, there was no difference for myocardial infarction or mortality.

"More than a quarter of the world's adult population, totaling nearly one billion people, have hypertension, and far too many-are still treated with beta-blockers (mainly for hypertension) even though better and affordable drugs are available," Dr. Lindholm and colleagues wrote.

The authors also noted that, because various anti-hypertensive agents used today-including thiazide diuretics, calcium antagonists, ACE inhibitors, angiotensin-receptor blockers and beta-blockers-appear to offer equal efficacy in lowering brachial blood pressure, the most appropriate treatment for people with primary hypertension may be the least expensive alternative.

An accompanying editorial by D. Gareth Beevers, MD, professor of medicine at the University of Birmingham in England, cautioned that abrupt cessation of beta-blockers could potentially harm some patients.

"It will be interesting to see how the many guidelines committees respond to the latest information," Beevers wrote, according to MedPage Today. "Their current endorsement of beta-blockers must surely be changed. But in the process they may be in danger of 'throwing out the baby with the bath water.' Some patients genuinely do need beta-blockers as their first line therapy, and there are also distinct theoretical hazards from their rapid discontinuation, particularly in patients who might be judged to be 'coronary prone.'"

Instead, use of beta-blockers should be slowly tapered while other anti-hypertensive agents are substituted, Beevers wrote.

Beta-Blockers Called Poor Choice for Hypertension, MedPage Today, 18 October 2005.
Should β blockers remain first choice in the treatment of primary hypertension? A meta-analysis, Lars Hjalmar Lindholm et al., The Lancet Early Online Publication, 18 October 2005
The end of β blockers for uncomplicated hypertension? Beevers DG, The Lancet, volume 366, number 9495, 22 October 2005.

Also covered by: BBC News, Forbes, MSN

Posted: October 2005