Beta-blockade should not be among several choices for initial therapy of hypertension

Adding a low-dose antihypertensive regimen would substantially improve the control of hypertension and reduce cardiovascular morbidity among uncomplicated hypertensive patients

AIMS

To assess the utilization of antihypertensive drugs among uncomplicated hypertensive patients in Finland between 2000 and 2006 and to calculate the achievable reduction in cardiovascular morbidity, with intensified antihypertensive treatment.

METHODS

From the databases of the Social Insurance Institution of Finland, 428,986 treated hypertensives without diabetes or cardiac disease (further named uncomplicated hypertensives) in 2000 and 591,206 in 2006, respectively, were identified. In addition, from the Health 2000 survey representing the whole Finnish adult population, 729 uncomplicated hypertensives were determined to assess their characteristics and control of hypertension. Applying Law's meta-analyses we calculated the reduction of blood pressure (BP) by intensifying the treatment with low-dose antihypertensive regimens for those with a BP ≥140/90 mmHg.

RESULTS

The nationwide data suggests a relative overuse of beta-blockers. Combination antihypertensive treatment increased relatively 8%, while at least three drug combinations increased from 19.8% to 21.6% between 2000 and 2006. However, calculated prevalence of controlled BP (<140/90 mmHg) increased only from 30.3% to 33.9%. Addition of one half standard dose or one to two half standard doses for the treatment of the patients with a BP ≥140/90 mmHg would improve the control of hypertension from 33.9% to 47.8% and 67.3%, respectively. The intensified treatment would reduce strokes by 18% and 28%, and ischaemic heart disease events by 13% and 21%, respectively.

CONCLUSIONS

Underutilization of preferred drugs and poor control of BP continues. Surprisingly small addition of the number of low-dose antihypertensive regimen is needed in order to substantially improve the control of hypertension and to decrease cardiovascular morbidity among uncomplicated hypertensive patients.

Role of beta-adrenergic receptor blocking agents in hypertensive diseases: personal thoughts as the controversy persists

The long history of the beta-adrenergic receptor blockers for the treatment of hypertension is fraught with many controversies. The first compound had severe untoward effects preventing their use until propranolol was introduced. It was found effective for treatment of angina pectoris since not all patients with hypertension responded to monotherapy with a meaningful reduction of pressure. Nevertheless, the beta-blockers were most effective in: younger patients, especially with hyperkinetic circulation; with co-morbid diseases (e.g. coronary arterial disease with or without prior myocardial infarction); or when used with a diuretic. Subsequently with the advent of meta-analysis to evaluate more generalized experience, controversy resumed with statements made to exclude beta-blockers for initial hypertensive therapy. Support for this argument was gained with reports of patients developing 'dysglycemia' with treatment. However, exclusion of any one therapeutic class for a multifactorial disease such as hypertension seems unrealistic. Meta-analysis confounded this conclusion since inadequate numbers of patients having specific clinical and biological characteristics were included (especially young patients). This is particularly important at this time when third-party reimbursement procedures are particularly relevant and when the primary care physician must deal with the individual patient. The NICE report has introduced specific thinking along these lines. In-and-of itself, its recommendations are reasonable, but current articles continue to suggest that the 'older' beta-blockers should be excluded from national guidelines for initial antihypertensive therapy. Personally, I disagree; and, no doubt, controversy will continue.