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#15 Atenolol & Beta-Blockers for Primary Hypertension: Do They Perform Under Pressure?


CLINICAL QUESTION
QUESTION CLINIQUE
Are beta-blockers, particularly atenolol, as effective as other antihypertensive medications in preventing important outcomes in hypertensive patients?


BOTTOM LINE
RÉSULTAT FINAL
Atenolol is an inferior choice for blood pressure treatment. Other antihypertensive classes (ACEI/ARB, calcium-channel blocker, diuretic) should all generally be considered first before using beta-blockers in patients with uncomplicated hypertension. 



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EVIDENCE
DONNÉES PROBANTES
Multiple large meta-analyses have examined this question: 
  • 2005 meta-analysis1 compared all beta-blockers against other antihypertensives (13 trials; 105,951 patients) over 2.7-10 years. 
    • Beta-blockers versus all other antihypertensives: 
      • Statistically significantly increased risk of stroke [Number Needed to Harm (NNH)=461]. 
      • No difference in myocardial infarction or death. 
    • Atenolol versus non-beta-blocker antihypertensives: 
      • Statistically significant increased stroke (NNH ~130) and death (NNH ~140). 
  • Similar results in 2004 meta-analysis by same authors,2 Cochrane review,3 and newer meta-analysis.4  
    • Beta-blockers worse than ACEIs/ARBs, calcium-channel blockers, and diuretics.4 
  • 2006 meta-analysis5 stratifying trials by age subgroup found different effects when comparing beta-blockers to other antihypertensives: 
    • <60 years: Relative risk 0.97 (0.88-1.07). 
    • >60 years: Relative risk 1.06 (1.01-1.10). 
    • Limitations: Age cutoff arbitrary and based on trial-wide mean age rather than individual-patient data, thus between-age difference could merely be due to chance or methodological differences between trials. 
  • 2014 meta-analysis found largely consistent results between atenolol and other beta-blockers versus other antihypertensives.6 
Limitations: Atenolol was the beta-blocker taken by 75% of trial participants,3 multiple different comparator drugs from different classes pooled together.    Context:  
  • Guidelines recommend against beta-blockers as 1st-line therapy for uncomplicated hypertension in general (UK7) or specifically in patients >60 years (Canada8), unless there are comorbid conditions which benefit from beta-blockers. 
  • Beta-blockers are highly effective agents in patients with other indications (such as post-myocardial infarction9 or heart failure with reduced ejection fraction10). 


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Author(s)
Auteur(s)
  • Christina Korownyk MD CCFP
  • G. Michael Allan MD CCFP

1. Lindholm LH, Carlberg B, Samuelsson O. Lancet. 2005; 366:1545-53.

2. Carlberg B, Samuelsson O, Lindholm LH. Lancet. 2004; 364:1684-9.

3. Wiysonge CS, Bradley HA, Volmink J, et al. Cochrane Database Syst Rev. 2012; 11:CD002003.

4. Ettehad D, Emdin CA, Kiran A, et al. Lancet. 2016; 387:957-67.

5. Khan N, McAlister FA. CMAJ. 2006; 174:1737-42.

6. Kuyper LM, Khan NA. Can J Cardiol. 2014; 30:S47-S53.

7. NICE Hypertension Guidelines. 2011. Available for download at: https://www.nice.org.uk/guidance/cg127/. Last accessed: August 22, 2016.

8. Leung AA, Nerenberg K, Daskalopoulou SS, et al. Can J Cardiol. 2016; 32:569-88.

9. Freemantle N, Cleland J, Young P, et al. BMJ. 1999; 318:1730-7.

10. Ko DT, Hebert PR, Coffey CS, et al. Arch Intern Med. 2004; 164:1389-94.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.