Beta-receptor blockers in primary prevention for cardiovascular disease: forgotten benefits?

Abstract

Beta-receptor blockers have been around for more than 35 years in cardiovascular medicine, 1 and used for a variety of conditions including treatment of hypertension, 2,3 congestive heart failure, 4,5 migraine, 6-8 heart palpitations and other cardiac arrhythmias, 9-11 and as secondary prevention [12][13][14] following myocardial infarction. Recently, two sets of meta-analyses published in the Lancet 15,16 have cast doubts on the usefulness of beta-receptor blockers for use in essential hypertension. These doubts were first raised for atenolol, 15 but then expanded to include also other beta-receptor blockers based on meta-analyses of 13 trials. 16 Even if it is fully appropriate that from time to time to make critical analyses of established dogmas and therapies in medicine, we feel that not all arguments have been voiced in defence of betareceptor blocker therapy for essential hypertension. In order to make the current debate on the role of beta-receptor blockers more multidimensional, we wanted to scrutinize the arguments against the beta-receptor blockers and to put forward some arguments in defence of this therapy.First of all, drugs are not only prescribed for more or less abstract risks in the future, but to patients presenting from symptoms in everyday life related to real health problems. Even if some individuals will not be able to tolerate beta-receptor blockers owing to side effects, it is a well-documented clinical experience that many patients suffering from migraine, heart palpitations or anxiety may feel symptomatic relief after starting beta-receptor blocker therapy. [6][7][8][9][10][11] This is a clinical argument that should not be overlooked, especially as many general practitioners face patients with a variety of symptoms presented at the consultation, not only the more or less precisely measured blood pressure value that will eventually qualify for antihypertensive treatment.Secondly, we know that during 35 years of development, we have seen a number of different beta-receptor blockers, ranging from the older nonselective ones (e.g. propranolol, oxprenolol) to the more modern, selective ones (atenolol, metoprolol), and with dual receptor-mediated effects (carvedilol, bisoprolol). During this development, there has also been one example of a beta-receptor blocker (practolol) that was stopped due to serious adverse effects in the early 1970s. This is to say that the beta-receptor blockers are not created all the same, and thus differ in chemical properties, lipidophilic structure and specificity for the beta-adrenergic receptor. 17 New data have also shown that the genetic background of the patient may determine clinical effects on glucose metabolism and lipid levels in patients receiving beta-receptor blocker therapy. 18 This class of drugs is therefore heterogeneous, both in a pharmacological sense and in the individual clinical effects when given to patients.Thirdly, a substantial proportion of patients with so-called essential hypertension may in fact have target organ damage 19 including...

Beta-Blockers for Primary Prevention of Heart Failure in Patients With Hypertension

“…However, this meta-analysis by Lindholm et al (9) did not evaluate the end point of HF, and some investigators have speculated that the deleterious effects on stroke prevention could be balanced by better effects on prevention of HF (37) and hence have continued to endorse it. Blood pressure reduction and risk of HF.…”

Optimizing the Pharmacologic Treatment of Hypertension

“…Data were colpublished in The Lancet, [23,24] even if arguments in defense of β-lected on smoking habits, BP control, total and low-density lipoblocker therapy have also been voiced. [25] These drugs do possess protein-cholesterol (LDL-C), diabetes mellitus, left ventricular some clinical benefits that should not be forgotten, e.g. in secondahypertrophy (LVH), and microalbuminuria, from records of 4424 ry prevention and in symptom relief (migraine and arrythmias).…”

Hypertension in the elderly: a compelling contraindication for β-blockers?

“…[14][15][16] However, before we throw away the 'baby' with the 'bathing water', 17 it must be emphasized that there is good evidence to support the use of b-blockers in patients with heart failure, post-MI and other indications, and it remains to be seen if the newer vasodilating b-blockers have a more favourable effect in patients with hypertension. 18 This brings up the, perhaps, somewhat philosophical question of the two for one (twofer). In a hypertensive patient with a compelling indication for b-blockade, should the b-blocker be used both for hypertension and the compelling indication (twofer)?…”