Beta-blockers and the treatment of hypertension: it is time to move on

Beta-blockers and the treatment of hypertension: it is time to move on tensive treatment was commenced with a beta-blocker than for those who received a renin-angiotensin system inhibitor [rela-tive risk increase (RRI) 30%, 95% CI 11–53%] or a calcium channel blocker (RRI 24%, 95% CI 11–40%). In addition, the risk of death from any cause (RRI 7%, 95% CI 0–14%) and any cardiovascular event (RRI 18%, 95% CI 8–29%) was higher for patients on beta-blockers than those on calcium channel block-ers. 3 It has also been shown that beta-blockers significantly increase the risk of new-onset diabetes compared to placebo (RRI 25%, 95% CI 5–50%), renin-angiotensin system inhibitors and calcium channel blockers. 7 When medication costs and the costs associated with treatment of hypertension-related and antihypertensive-induced complications are considered, beta-blockers are less cost-effective than thiazide diuretics, renin-angiotensin system inhibitors and calcium channel blockers. 8 It is important to note that the current evidence derives mainly from trials of first-and second-generation beta-block-ers (mainly atenolol), as there are no outcome data yet on third-generation beta-blockers. 3 The sub-optimal cardiovascular protection with conventional (ie, first-and second-generation) beta-blockers may be due to the development of new-onset diabetes and the inability to decrease central aortic pressure as much as brachial pressure. 9 In theory, third-generation beta-blockers should reduce central blood pressure more than conventional beta-blockers because vasodilatation by the former may alter the pattern of the pressure wave reflecting back from the periphery. In addition, the newer beta-blockers may have a better metabolic profile. 10 Clinicians should use the currently available scientific evidence 3,7,8 to guide the management of their patients with hypertension but this does not yet seem to be the case. Beta-blockers are still widely used worldwide. For example, 12 to 29% of patients on antihypertensive drugs in various European countries are on beta-blockers, a substantial proportion on aten-olol. 11 We think it is now time to move on. There is a need for long-term, outcome-randomised, controlled trials to compare the effects of third-generation beta-blockers 10 with those of renin-angiotensin system inhibitors and calcium channel block-ers. In the meantime, guideline developers should no longer recommend beta-blockers for initiating antihypertensive treatment. Similarly, conventional beta-blockers should no longer be used as comparator drugs in randomised, controlled hyperten-sion trials. We do, however, acknowledge that some patients with hypertension may require beta-blockers for symptomatic angina, chronic stable heart failure and post-myocardial infarc-Editorial Existing solid scientific evidence with hard …