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Clinical Review

β blockers in hypertension and cardiovascular disease

BMJ 2007; 334 doi: (Published 03 May 2007) Cite this as: BMJ 2007;334:946
  1. H T Ong, consultant cardiologist
  1. H T Ong Heart Clinic, 251C Burma Road, Penang, Malaysia
  1. htyl{at}
  • Accepted 27 March 2007

This review provides practical pointers on the use of β blockers for the non-specialist clinician

β blockers are useful in managing angina and reducing mortality after myocardial infarction and in heart failure. They probably reduce cardiovascular events in high risk surgery and retard the progression of atherosclerosis. In younger patients, β blockers should remain first line antihypertensives, together with diuretics, calcium channel blockers, angiotensin converting enzymes, and adrenergic receptor binders; choice depends on the individual case.

Not all β blockers are equivalent in cardiovascular protective effects, and atenolol seems inferior to other antihypertensive drugs in reducing stroke and total mortality. Recent publications have found that β blockers are less effective than other antihypertensive drugs in preventing cardiovascular outcomes in hypertensive patients.1 2 3 In interpreting the new data, it is important to integrate these new results with previous trials and meta-analyses.

Sources and selection criteria

The references in the ASCOT trial,1 recent meta-analyses of treatment with β blockers,2 3 and guidelines of hypertension societies (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), British Hypertension Society, World Health Organization, European Society of Hypertension–European Society of. Cardiology) were supplemented with a PubMed search using the keywords “clinical trial”, “beta-blockers”, “hypertension”, and “cardiovascular outcomes”.

Are β blockers less protective in hypertensive patients?

Results of ASCOT-BPLA (the Anglo-Scandinavian cardiac outcomes trial—blood pressure lowering arm) suggest that atenolol may be only marginally inferior to amlodipine.1 Its main lesson is that blood pressure must be tightly controlled, and patients taking β blockers (and diuretics) must be monitored so that cardiovascular risk factors are not adversely altered.

ASCOT-BPLA randomised 19 257 high risk people with hypertension to amlodipine (adding perindopril) or atenolol (adding bendroflumethiazide). After 5.5 years, the primary end point, non-fatal myocardial infarction and cardiovascular death, was similar in the two groups (relative risk 0.90, 95% confidence interval …

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