- Email: [email protected]
Beta-blockers may be less effective than other antihypertensives
ARTICLE IN PRESS Evidence-based Cardiovascular Medicine (2006) 10, 13–14
Evidence-based
CARDIOVASCULAR MEDICINE www.elsevier.com/locate/ebcm
HYPERTENSION
Beta-blockers may be less effective than other antihypertensives$ Bert-Jan H van den Born, Gert A van Montfrans, Debbie Singh Background
Main results
Guidelines recommend beta-blockers as first-line treatment in hypertension. However, preliminary data suggest that some beta-blockers may have limited effectiveness in hypertension.
Beta-blockers were associated with a higher risk of stroke compared to other antihypertensives (16% higher relative risk, 95% CI 9% to 30%). There was no difference in myocardial infarction.
Objective Lindholm and colleagues assessed the effectiveness of different beta-blockers in hypertension.
Authors’ conclusions The authors concluded that beta-blockers are less effective than other antihypertensive drugs, and may be associated with an increased risk of stroke.
Method The authors searched the Cochrane Library and PubMed for systematic reviews and randomised controlled trials of beta-blockers in people with primary hypertension. 13 trials (n=105,951) were included in a metaanalysis comparing beta-blockers with other antihypertensive drugs. Seven trials (n=27,433) were included in a meta-analysis comparing beta-blockers and placebo or no treatment. Most participants were older than 60 and there was significant statistical heterogeneity. Heterogeneity was the rationale behind splitting analyses into non-atenolol, mixed, and atenolol groupings.
$ Abstracted from Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005; 366(9496): 1545–53.
Overall quality
topic importance method quality practical use Poor
Fair
Good
Excellent
Commentary Hypertension affects 25% of the population in developed countries and is a major risk factor for cardiovascular disease. Current guidelines recommend beta-blockers as a first-line treatment, however their effectiveness is disputed.
1361-2611/$ - see front matter & 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ebcm.2006.01.021
ARTICLE IN PRESS 14
Implications This meta-analysis suggests that first and second generation beta-blockers are less effective in lowering blood pressure and preventing stroke than other anti-hypertensive drugs. It extends a previous meta-analysis, which found that beta-blockers were less effective than diuretics in blood pressure reduction and in preventing stroke, myocardial infarction and all-cause mortality in people older than 60.2 A pathophysiological argument for this finding is that plasma renin activity and sympathetic tone, primary targets for beta-blocker therapy, decrease with age which make them less successful in the elderly.3 The previous meta-analysis included non-comparative trials on monotherapy with beta-blockers and thiazide diuretics. Lindholm’s analysis, which includes only comparative trials, provides more solid evidence to reconsider the role of betablockers.
B.-J.H. van den Born et al. One characteristic the included studies had in common, however, was the advanced age of participants, which on average exceeded 60 years. Therefore the conclusion that beta-blockers should not be used as a first line agent in people with hypertension should be restricted to elderly persons (aged 60 or above) rather than applied to the population at large. The authors analysed outcomes for atenolol and non-atenolol beta-blockers separately, but found no significant difference on any outcome. This was probably due to lack of power, as there were few studies comparing non-atenolol beta-blockers with other antihypertensive drugs and most had a limited sample size. Like the authors, we see no reason why the results should be different for other first and second generation beta-blockers. The new generation of NO-donating beta-blockers (such as nebivolol) need to be exempted from these findings. Their modes of action need a separate analysis. Study sponsored by County of Va ¨sterbotten, Sweden.
Caveats
Enquiries to [email protected] Results abstracted by Debbie Singh, Editor.
There was statistically significant heterogeneity in the studies included in the meta-analysis. This may be caused by the different characteristics of study populations. For example, studies including people with hypertension and left ventricular hypertrophy (LIFE) were pooled with studies including only diabetics (UKPDS). Studies including only elderly hypertensives (MRC-Old and STOP-2) were pooled with studies including hypertensive people with coronary artery disease (INVEST). These population differences did not seem to be associated with the response to beta-blockers so this heterogeneity is probably of minor importance. It may also offer advantages as the results can be generalised to a wider population.
Commentary provided by Bert-Jan H van den Born MD and Gert A van Montfrans MD, PhD, Department of Internal and Vascular Medicine, Academic Medical Centre, Amsterdam, the Netherlands.
References 1. Messerli FH, Grossman E, Goldbourt U. Are b-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. JAMA 1998; 279: 1903-7. 2. Phillips PA, Hodsman GP, Johnston CI. Neuroendocrine mechanisms and cardiovascular homeostasis in the elderly. Cardiovasc Drugs Ther 1991; 4 Suppl 6: 1209-13.
Evidence-based
CARDIOVASCULAR MEDICINE www.elsevier.com/locate/ebcm
HYPERTENSION
Beta-blockers may be less effective than other antihypertensives$ Bert-Jan H van den Born, Gert A van Montfrans, Debbie Singh Background
Main results
Guidelines recommend beta-blockers as first-line treatment in hypertension. However, preliminary data suggest that some beta-blockers may have limited effectiveness in hypertension.
Beta-blockers were associated with a higher risk of stroke compared to other antihypertensives (16% higher relative risk, 95% CI 9% to 30%). There was no difference in myocardial infarction.
Objective Lindholm and colleagues assessed the effectiveness of different beta-blockers in hypertension.
Authors’ conclusions The authors concluded that beta-blockers are less effective than other antihypertensive drugs, and may be associated with an increased risk of stroke.
Method The authors searched the Cochrane Library and PubMed for systematic reviews and randomised controlled trials of beta-blockers in people with primary hypertension. 13 trials (n=105,951) were included in a metaanalysis comparing beta-blockers with other antihypertensive drugs. Seven trials (n=27,433) were included in a meta-analysis comparing beta-blockers and placebo or no treatment. Most participants were older than 60 and there was significant statistical heterogeneity. Heterogeneity was the rationale behind splitting analyses into non-atenolol, mixed, and atenolol groupings.
$ Abstracted from Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005; 366(9496): 1545–53.
Overall quality
topic importance method quality practical use Poor
Fair
Good
Excellent
Commentary Hypertension affects 25% of the population in developed countries and is a major risk factor for cardiovascular disease. Current guidelines recommend beta-blockers as a first-line treatment, however their effectiveness is disputed.
1361-2611/$ - see front matter & 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ebcm.2006.01.021
ARTICLE IN PRESS 14
Implications This meta-analysis suggests that first and second generation beta-blockers are less effective in lowering blood pressure and preventing stroke than other anti-hypertensive drugs. It extends a previous meta-analysis, which found that beta-blockers were less effective than diuretics in blood pressure reduction and in preventing stroke, myocardial infarction and all-cause mortality in people older than 60.2 A pathophysiological argument for this finding is that plasma renin activity and sympathetic tone, primary targets for beta-blocker therapy, decrease with age which make them less successful in the elderly.3 The previous meta-analysis included non-comparative trials on monotherapy with beta-blockers and thiazide diuretics. Lindholm’s analysis, which includes only comparative trials, provides more solid evidence to reconsider the role of betablockers.
B.-J.H. van den Born et al. One characteristic the included studies had in common, however, was the advanced age of participants, which on average exceeded 60 years. Therefore the conclusion that beta-blockers should not be used as a first line agent in people with hypertension should be restricted to elderly persons (aged 60 or above) rather than applied to the population at large. The authors analysed outcomes for atenolol and non-atenolol beta-blockers separately, but found no significant difference on any outcome. This was probably due to lack of power, as there were few studies comparing non-atenolol beta-blockers with other antihypertensive drugs and most had a limited sample size. Like the authors, we see no reason why the results should be different for other first and second generation beta-blockers. The new generation of NO-donating beta-blockers (such as nebivolol) need to be exempted from these findings. Their modes of action need a separate analysis. Study sponsored by County of Va ¨sterbotten, Sweden.
Caveats
Enquiries to [email protected] Results abstracted by Debbie Singh, Editor.
There was statistically significant heterogeneity in the studies included in the meta-analysis. This may be caused by the different characteristics of study populations. For example, studies including people with hypertension and left ventricular hypertrophy (LIFE) were pooled with studies including only diabetics (UKPDS). Studies including only elderly hypertensives (MRC-Old and STOP-2) were pooled with studies including hypertensive people with coronary artery disease (INVEST). These population differences did not seem to be associated with the response to beta-blockers so this heterogeneity is probably of minor importance. It may also offer advantages as the results can be generalised to a wider population.
Commentary provided by Bert-Jan H van den Born MD and Gert A van Montfrans MD, PhD, Department of Internal and Vascular Medicine, Academic Medical Centre, Amsterdam, the Netherlands.
References 1. Messerli FH, Grossman E, Goldbourt U. Are b-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. JAMA 1998; 279: 1903-7. 2. Phillips PA, Hodsman GP, Johnston CI. Neuroendocrine mechanisms and cardiovascular homeostasis in the elderly. Cardiovasc Drugs Ther 1991; 4 Suppl 6: 1209-13.