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STATE-OF-THE-ART PAPER

Cardiovascular Protection Using Beta-Blockers

A Critical Review of the Evidence

Sripal Bangalore, MD, MHA^_*, Franz H. Messerli, MD^_*,1,_*, John B. Kostis, MD^,2 and Carl J. Pepine, MD^,3

^_* St. Luke’s-Roosevelt Hospital and Columbia University, New York, New York
University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey
University of Florida College of Medicine, Gainesville, Florida.

Manuscript received February 14, 2007; revised manuscript received April 13, 2007, accepted April 30, 2007.

^_* Reprint requests and correspondence: Dr. Franz H. Messerli, Director, Hypertension Program, Division of Cardiology, St. Luke’s-Roosevelt Hospital, Columbia University College of Physicians and Surgeons, 1000 10th Avenue, Suite 3B-30, New York, New York 10019. (Email: fmesserl{at}chpnet.org).

For more than 3 decades, beta-blockers have been widely used in the treatment of hypertension and are still recommended as first-line agents by national and international guidelines. Recent meta-analyses indicate that, in patients with uncomplicated hypertension, compared with other antihypertensive agents, first-line therapy with beta-blockers was associated with an increased risk of stroke, especially in the elderly cohort with no benefit for the end points of all-cause mortality, cardiovascular morbidity, and mortality. In this review, we critically analyze the evidence supporting the use of beta-blockers in patients with hypertension and evaluate evidence for its role in other indications. The review of the currently available literature shows that in patients with uncomplicated hypertension, there is a paucity of data or absence of evidence to support use of beta-blockers as monotherapy or as first-line agents. Given the increased risk of stroke, their "pseudo-antihypertensive" efficacy (failure to lower central aortic pressure), lack of effect on regression of target end organ effects like left ventricular hypertrophy and endothelial dysfunction, and numerous adverse effects, the risk benefit ratio for beta-blockers is not acceptable for this indication. However, beta-blockers remain very efficacious agents for the treatment of heart failure, certain types of arrhythmia, hypertropic obstructive cardiomyopathy, and in patients with prior myocardial infarction.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   CI = confidence interval   HR = hazard ratio   JNC = Joint National Committee   LVH = left ventricular hypertrophy   MI = myocardial infarction   NNH = number needed to harm   RAAS = renin angiotensin aldosterone system

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