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Atenolol, a cardioselective β-blocker, is the most widely prescribed β-blocker for the treatment of

hypertension in the United States.1 Atenolol has been used in hypertension studies as a standard treatment and has been compared with various other agents. Recently, several large hypertension studies using atenolol have reported less favorable patient out-comes when compared with other agents, most espe-cially among older patients.2,3 Yet substantial data for a broad range of patient populations and risk groups have established that β-blockers significantly reduce cardiovascular morbidity and mortality in patients with hypertension and concomitant condi-tions like coronary artery disease.1 These discordant findings have called into question the indication for using β-blockers in uncomplicated hypertension.4,5 Why might this be so, and are all β-blockers tarred with the same brush as atenolol?

Briefly, 2 investigations (the Losartan Intervention For Endpoint reduction in hypertension study [LIFE]2 and the Anglo-Scandanavian Cardiac Outcomes Trial [ASCOT]3) were performed in older patients with hypertension and high cardiovascular risk comparing an atenolol-based and a losartan-2 or amlodipine-based treatment regimen.3 Nearly iden-tical BP reduction was achieved in both studies with the different medications but, despite this, the out-comes favored the comparator drug in both studies. This finding has now been verified (for atenolol) in

several other studies and with other (non-atenolol) β-blockers.4 In ASCOT,3 the blood pressure differ-ence between the β-blocker and the calcium channel blocker group over the first few months of the trial, although small, may have accounted for at least some of the differences in cardiovascular outcome.

As we know, β-blockers are a heterogeneous class of drugs. Newer agents such as carvedilol, which has some α-blocker action, and the highly cardioselective agent nebivolol,6 which is under review but not approved in the United States, have been shown to have an improved hemodynamic profile when compared with atenolol. Carvedilol (in the United States) may be a reasonable alter-native when a β-blocker is considered for use in uncomplicated hypertension.

Several reasons may explain the less favorable outcomes with β-blocker therapy. These include some adverse metabolic effects (lowering of high-density lipoprotein cholesterol and an increased risk of developing diabetes), possible better effi-cacy with twice-daily dosing with atenolol, and less effective reduction of central aortic compared with brachial blood pressures.7

In our hypertension practice, we now recom-mend that β-blockers not be considered as first-line therapy in uncomplicated hypertension, especially in older patients. In patients who are already on atenolol as part of their regimen, we discuss either leaving atenolol in their regimen at a twice-daily dose or raise the issue of switching to either anoth-er antiadrenergic β-blocking agent (like carvedilol) or to a different class of antihypertensive medica-tion on a case-by-case basis.

REFERENCES 1 The Seventh Report of Joint National Committee on Prevention.

Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560–2572.

2 Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular

From the Department of Medicine, Hypertension Program, University of Pennsylvania School of Medicine, Philadelphia, PAAddress for correspondence: Raymond R. Townsend, MD, Department of Medicine, Hypertension Program, University of Pennsylvania School of Medicine, White Building, 3400 Spruce Street, Philadelphia, PA 19104E-mail: townsend@mail.med.upenn.edu.com

C o m m o n Q u e s t i o n s a n d A n s w e r s i n t h e M a n a g e m e n t o f H y p e r t e n s i o nR a y m o n d R . T o w n s e n d , M D , S e c t i o n E d i t o r

www.lejacq.com ID: 5178

Update on β-Blockers in Hypertension

Debbie L. Cohen, MD; Raymond R. Townsend, MD

The Journal of Clinical Hypertension® (ISSN 1524-6175) is published monthly by Le Jacq, Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2006 by Le Jacq, All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at showell@lejacq.com or 203.656.1711 x106.

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THE JOURNAL OF CLINICAL HYPERTENSION VOL. 8 NO. 12 DECEMBER 2006900

morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a ran-domised trial against atenolol. Lancet. 2002;359:995–1003.

3 Dahlof B, Sever PS, Poulter NR, et al. Prevention of car-diovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895–906.

4 Lindholm LH, Carlberg B, Samuelsson O. Should beta

blockers remain first choice in the treatment of primary hyper-tension? A meta-analysis. Lancet. 2005;366:1545–1553.

5 Moser M, Pickering TG, Cushman WC. The role of beta blockers in the management of hypertension. J Clin Hypertens (Greenwich). 2005;7:295–299.

6 Mason RP. Nitric oxide mechanisms in the pathogenesis of global risk. J Clin Hypertens (Greenwich). 2006;8(8 suppl 2):31–38.

7 Wilkinson IB, McEniery CM, Cockcroft JR. Atenolol and cardiovascular risk: an issue close to the heart. Lancet. 2006;367:627–629.

The Journal of Clinical Hypertension® (ISSN 1524-6175) is published monthly by Le Jacq, Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2006 by Le Jacq, All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at showell@lejacq.com or 203.656.1711 x106.

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