Evidence is needed that ß blockade alone reduces mortality in hypertension

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7121.1544 (Published 06 December 1997) Cite this as: BMJ 1997;315:1544
  1. L H Opie, Director, heart research unit and hypertension clinic (Opie{at}samiot.uct.ac.za)a
  1. a Department of Medicine, UCT Medical School, Observatory 7925, Cape Town, South Africa

    Editor—I am concerned by the oft repeated but incorrect statement that “reduction in mortality has been shown only with established ß blockers and diuretics,” which is one of the key messages of Philipp et al's paper on the HANE study.1 I have no quarrel with the diuretic part of the statement, which is well supported by good trials. However, the idea that monotherapy with a ß blocker, as in the HANE study, can reduce mortality is simply incorrect.

    Reference is made to the meta-analysis by Collins et al in 1990.2 That meta-analysis was of 14 unconfounded studies, of which only two were on ß blockade. One was a small study in elderly people,3 which has now been superseded by the Medical Research Council's mega-study in elderly people.4 In the mega-study the ß blocker atenolol did not reduce mortality when compared with placebo (whereas the diuretic did). Cardiovascular mortality seemed to increase in the atenolol group. In the Swedish trial in old patients with hypertension, in which mortality was reduced, initial ß blockade was indeed one of the arms of treatment, but over two thirds of patients received an added diuretic.5 (If the proposal is that combined treatment with ß blockade and diuretic can reduce mortality then there are indirect supporting data from the Swedish trial.) In the Medical Research Council's trial in middle aged people, propranolol had only modest effects in non-smokers and conferred little or no benefit in smokers. Mortality was not decreased, and the trial was not powered for mortality. Two other studies that Philipp et al cite, in which mortality was reduced, refer to initial treatment with diuretics, not with ß blockers.

    In this era of evidence based medicine, exactly where is the evidence that monotherapy with a ß blocker reduces mortality in hypertension?


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