Should B-blockers remain first choice in the treatment of primary hypertension? A meta-analysis

Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden.
The Lancet (Impact Factor: 45.22). 10/2005; 366(9496):1545-53. DOI: 10.1016/S0140-6736(05)67573-3
Source: PubMed


Beta blockers have been used widely in the treatment of hypertension and are recommended as first-line drugs in hypertension guidelines. However, a preliminary analysis has shown that atenolol is not very effective in hypertension. We aim to substantially enlarge the data on atenolol and analyse the effect of different beta blockers.
The Cochrane Library and PubMed were searched for beta blocker treatment in patients with primary hypertension. Data were then entered into the Cochrane Collaboration Review Manager package and were summarised in meta-analyses. 13 randomised controlled trials (n=105 951) were included in a meta-analysis comparing treatment with beta blockers with other antihypertensive drugs. Seven studies (n=27 433) were included in a comparison of beta blockers and placebo or no treatment.
The relative risk of stroke was 16% higher for beta blockers (95% CI 4-30%) than for other drugs. There was no difference for myocardial infarction. When the effect of beta blockers was compared with that of placebo or no treatment, the relative risk of stroke was reduced by 19% for all beta blockers (7-29%), about half that expected from previous hypertension trials. There was no difference for myocardial infarction or mortality.
In comparison with other antihypertensive drugs, the effect of beta blockers is less than optimum, with a raised risk of stroke. Hence, we believe that beta blockers should not remain first choice in the treatment of primary hypertension and should not be used as reference drugs in future randomised controlled trials of hypertension.

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    • "Allerdings ist eine heftige Debatte aufgekommen, die sich mit dem Stellenwert der Betarezeptorenblocker in Stufe I der Therapie befasst (DiNicolantonio et al. 2015). Eine Metaanalyse von 13 kontrollierten Studien kam zu dem Ergebnis, dass Betarezeptorenblocker nicht mehr erste Wahl bei der Behandlung der primären Hypertonie sein sollten (Lindholm et al. 2005). Dies wurde in zahlreichen Stellungnahmen (Beevers 2005, Deutsche Hoch­ druckliga 2008, Kintscher et al. 2014) nicht geteilt. "

    Arzeiverordnungs-Report 2015, Edited by U. Schwabe, D. Paffrath, 01/2015: chapter Betarezeptorenblocker: pages 535-546; Springer-Verlag, Berlin Heidelberg New York.
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    • "The choice of antihypertensive treatment, particularly for the firstline agent, should be made with caution as it could significantly affect clinical outcomes [13]. Existing guidelines, including those of the National Institute for Health and Clinical Excellence (NICE), the updated Eighth Joint National Committee (JNC 8th), and the reappraisal of the European hypertension guidelines in 2008 all recommended angiotensinconverting-enzyme (ACE) inhibitors as one of the preferred first-line agent for management of arterial hypertension [14] [15] [16] [17]. Nevertheless, there have not been explicit recommendations on which ACE inhibitor is more preferred. "
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    ABSTRACT: Background: Perindopril and lisinopril are two common ACE inhibitors prescribed for management of hypertension. Few studies evaluated their comparative effectiveness to reduce mortality. This study compared the all-cause and cardiovascular related mortality among patients newly prescribed ACE inhibitors. Methods: All adult patients newly prescribed perindopril or lisinopril from 2001 to 2005 in all public clinics or hospitals in Hong Kong were retrospectively evaluated, and followed up until 2010. Patients prescribed the ACE inhibitors for less than a month were excluded. The all-cause and cardiovascular-specific (i.e. coronary heart disease, heart failure and stroke) mortality were compared. Cox proportional hazard regression model was used to assess the mortality, controlling for age, sex, socioeconomic status, patient types, the presence of comorbidities, and medication adherence as measured by the Proportion of Days Covered. An additional model using propensity scores were performed to minimize indication bias. Results: A total of 15,622 patients were included in this study, in which 6,910 were perindopril users and 8,712 lisinopril users. The all-cause mortality (22.2% vs. 20.0%, p<0.005) and cardiovascular mortality (6.5% vs. 5.6%, p<0.005) were higher among lisinopril users than perindopril users. From regression analyses, lisinopril users were 1.09-fold (95% C.I. 1.01-1.16) and 1.18-fold (95% C.I. 1.02-1.35) more likely to die from any-cause and cardiovascular diseases, respectively. Age-stratified analysis showed that this significant difference was observed only among patients aged>70 years. The additional models controlled for propensity scores yielded comparable results. Conclusions: The long-term all-cause and cardiovascular related mortality of lisinopril users was significantly different from that of perindopril users. These findings showed the intra-class variation on mortality exists among ACE inhibitors among those aged 70 years or older. Future studies should consider a longer, large-scale randomized controlled trial to compare the effectiveness between different medications in the ACEI class, especially among the elderly.
    International Journal of Cardiology 07/2014; 176(3). DOI:10.1016/j.ijcard.2014.07.114 · 4.04 Impact Factor
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    • "Lack of improvement in central blood pressure is theorized to be at least in part responsible for the higher risk of stroke found in outcome trials with b-blockers compared with other antihypertensive agents in older patients. 8 As is pointed out in many of the articles included in this supplement of the CJC, the role of b-blockers in hypertension has been debated hotly since the publication of a meta-analysis on the subject by Lindholm et al. in 2005. 8 After this publication, b-blockers were relegated to fourth-line therapy by the National Institute for Health and Clinical Excellence on the management of hypertension from the United Kingdom, 9 and maintained only as a possible choice for antihypertensive treatment by the European Society of Hypertension, 10 and the Eighth Joint National Committee for hypertension in the United States. "

    The Canadian journal of cardiology 05/2014; 30(5). DOI:10.1016/j.cjca.2014.02.015 · 3.94 Impact Factor
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