![]() 2 Among recent guidelines, NICE and JNC8 guidelines exclude beta-blockers as a first-step drug, and the Canadian Hypertension Education Program guidelines exclude them in patients over 60 years.3, 4, 5 In contrast, the ESH/ESC guidelines include beta-blockers as a first-step option for all. 1 Some recent guidelines, reflecting those findings, have excluded beta-blockers as a first-step treatment option, even though their antihypertensive effect is comparable to that of other antihypertensive drug classes. Meta-analyses of large randomized controlled hypertension treatment trials have concluded that cardiovascular outcome is inferior when first-step treatment is commenced with a beta-blocker as compared to drugs from other antihypertensive drug classes. Clinical effectiveness could be improved with greater focus on the beta-blockers with the more favorable pharmacokinetics. Finally, unreliable bioavailability greatly interferes with the effectiveness of lipophilic, but not nonlipophilic, beta-blockers. In choosing among the beta-blockers, combined alpha/beta-blockade offers advantages over beta-blocker monotherapy and merits greater clinical and research attention. Beta-blockers would instead appear to be best suited for patients with sympathetically driven, that is, neurogenic, hypertension, whether as a first-step drug, such as in patients with hypertension in the acute post-stroke period, in so-called “hyperkinetic” patients, and in patients with labile hypertension, or as an add-on drug in patients with resistant hypertension. In the absence of comorbidities for which a beta-blocker is indicated, beta-blockers would not seem to be the preferred treatment for patients with either sodium/volume-mediated hypertension, for which they are usually ineffective, or for those with renin-angiotensin system–mediated hypertension, for which angiotensin-converting enzyme inhibitors and angiotensin receptor blockers provide equal antihypertensive efficacy with evidence of better outcome and fewer adverse effects. Identifying the right patient involves consideration of underlying mechanisms of hypertension. It is the contention of this perspective that beta-blockers do have an important role in treating hypertension, but their use needs to be much better targeted, by better identification of both the right patient and the right beta-blocker. Despite this, beta-blockers are still widely prescribed, and likely overused, in the management of hypertension. Consequently, some recent guidelines consider beta-blockers an inferior option for first-step treatment of hypertension. Beta-blocker use is also associated with undesirable side effects. Randomized controlled trials have concluded that the cardiovascular outcome of first-step treatment of hypertension with traditional vasoconstricting beta-blockers is inferior to treatment with other antihypertensive drug classes. ![]()
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