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Hypertension
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Hypertension Trials- How Useful are Beta-Blockers?A meta-analysis published in the Lancet suggested that atenolol (and presumably also other beta-blockers) was not a suitable first line drug in treatment of hypertension. In an attempt to answer the hypothesis, the investigators had to select trials that compared atenolol with placebo or no treatment. They found two trials that included patients with previous TIA or minor stroke, and two other trials that enrolled patients over the age of at least 60 years. In view of the age of these patients or the fact that they had had prior cerebrovascular events, one might assume these were patients at higher risk of a coronary heart event. Despite lowering blood pressure, in these four trials there was no favourable impact or trend towards a favourable impact on all cause mortality, on cardiovascular mortality or on myocardial infarction. However, there was a reduction in stroke. They also found a number of trials which compared atenolol with other anti-hypertensives. They found a significantly higher mortality (RR 1.13, CI 1.02-1.25) in the atenolol therapy group, there was also a trend towards higher cardiovascular mortality. These differences were present even if the large LIFE study was excluded from the analysis. This analysis excluded a number of other trials that were included in other meta-analysis. If we accept these conclusions, we would have to also wonder if other beta-blockers are equally less effective as atenolol, when used as monotherapy for treatment of hypertension. If we accept this analysis we would have to note that atenolol, compared with placebo, was not found to be harmful. However, the conclusions of other analysis was that atenolol was not quite as effective as other anti-hypertensive agents. The authors of this meta-analysis refer to studies showing that other beta-blockers (such as metoprolol, timolol and propranolol) have been showing to reduce death when used for secondary prevention after myocardial infarction. Atenolol has not been studied as well in this setting. The authors also state that because of lack of data it is not possible to evaluate the effectiveness of other beta-blockers for treatment of hypertension, as done for atenolol. This does not necessarilly mean we have to abandon use of atenolol (or other beta-blockers) and we can not ignore the evidence in favour of beta-blockers (including atenolol) in patients after myocardial infarction and including those with impaired left ventricular systolic function. The analysis raises doubts about the efficacy of using atenolol as monotherapy in higher risk patients (those with prior TIA or minor stroke and those over the age of at least 60 years). Most patients now-a-days that are at higher risk need multi-agent therapy and I suspect we should continue to use beta-blockers as part of multi-agent therapy that is required to ensure excellent control of hypertension. Hitesh Patel, Cardiologist Reference: Users should read this document on "copyright" and "conditions of use". |