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Beta blockers in the treatment of arterial hypertension

An article from the e-journal of the ESC Council for Cardiology Practice

The new guidelines of the JNC VII and the European Society of Hypertension/European Society of Cardiology now clearly suggest the use of beta-blockers whenever coronary heart disease, congestive heart failure, diabetes, tachyarrhythmias, atrial fibrillation, migraine, thyrotoxicosis, essential tremor, perioperative hypertension or pregnancy are present in addition to arterial hypertension.

Hypertension


Since almost four decades, beta-blockers have been used as cornerstones in the treatment of arterial hypertension, and their favourable effects on morbidity and mortality are well documented. In fact, in 1997 the Sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC VI) recommended beta-blockers (and diuretics) be used as first line antihypertensive agents in patients with no compelling indications for other classes of antihypertensives.(1) However, the publication of the LIFE study in March 2002 threw doubt on the usefulness of beta-blockers in the treatment of arterial hypertension since this trial revealed superiority of an angiotensin receptor-blocker, losartan, over a beta-blocker, atenolol, in terms of the composed primary end point of the study consisting of death, myocardial infarction, or stroke.(2)

However, this study was also criticised, particularly because only elderly with left ventricular hypertrophy were included – a population for which beta-blockers might be not so favourable – whereas patients with angina pectoris or myocardial infarction within the last six months were excluded – a population with a special indication for beta-blockers. Therefore, the new guidelines of the JNC VII (published in May 2003) (3) and the European Society of Hypertension / European Society of Cardiology (published in June 2003) (4) were expected to clarify the “new role” of beta-blockers in the treatment of arterial hypertension, and they did so as follows:

  • JNC VII (3) sees compelling indications for beta-blockers in arterial hypertension together with heart failure, post-myocardial infarction, high coronary disease risk and diabetes. The new guidelines of the European Society of Hypertension / European Society of Cardiology (4) see conditions favouring the use of beta-blockers when hypertension occurs together with angina pectoris, post-myocardial infarction, congestive heart failure, pregnancy or tachyarrhythmias, but they also give possible and compelling contraindications against the use of beta-blockers in hypertension.
  • Thus, as by 2003, we should treat patients with arterial hypertension as a whole rather than solely the symptom of high blood pressure. Therefore, beta-blockers should be used whenever there are compelling indications or conditions favouring their use but no contraindications (Table). Therapy should be guided according to the principle “Start low – go slow!”, particularly when heart failure is present. Furthermore, one should prescribe low-dose combinations rather than give maximum recommended doses of single drugs. In this context, beta-blockers combine favourably with diuretics, (dihydropyridine) calcium antagonists and alpha-blockers

Table: Beta-blockers in arterial hypertension

Compelling indications

  • Coronary heart disease
  • Myocardial infarction
  • Congestive heart failure

Conditions favouring the use

  • Diabetes
  • Tachyarrhythmias
  • Atrial fibrillation
  • Migraine
  • Thyrotoxicosis
  • Essential tremor
  • Perioperative
  • hypertension
  • Pregnancy

Compelling contraindications

  • Asthma / COPD
  • AV-block II° and III°

Possible contraindications

  • Peripheral vascular disease
  • Glucose intolerance
  • Athletes
  • Physically active patients

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

References


1. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 1997; 157: 2413-46
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9385294&dopt=Abstract

2. Dahlöf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, Faire U, Fyhrquist F, Ibsen H, Kristiansson K, Lederballe-Pedersen O, Lindholm LH, Nieminen MS, Omvik P, Oparil S, Wedel H. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359: 995-1003 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12117460&dopt=Abstract

3. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003; 289: 2560-2572
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12748199&dopt=Abstract

4. 2003 European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertension 2003; 21: 1011-1053
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12777938&dopt=Abstract

VolumeNumber:

Vol2 N°08

Notes to editor


Dr K. Stoschitzky
Secretary, ESC Working Group on Cardiovascular Pharmacology and Drug Therapy.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.