Tools for Practice


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


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


BOTTOM LINE
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
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):

  • 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.