CORRESPONDENCE: LETTER TO THE EDITOR
Beta-Blockers and Exercise
Sripal Bangalore, MD, MHA and
Franz H. Messerli, MD*
* Hypertension Program, Division of Cardiology, Columbia University College of Physicians and Surgeons, St. Luke’s–Roosevelt Hospital Center, 1000 Tenth Avenue, Suite 3B-30, New York, New York 10025 (Email: fmesserli{at}chpnet.org).
In a recent issue of JACC, Kokkinos et al. (1), after evaluating the role of beta-blockers at mitigating exercise-induced blood pressure (BP) rise in hypertensive men, concluded that "for patients engaging in vigorous activities such as snow-shoveling, basketball, tennis, racquetball, and so on, beta-blockade–based therapy can protect against excessive and repetitive elevations in BP which may occur during such activities."
Earlier studies have shown that beta-blockers bring about a clear reduction in exercise endurance in young healthy subjects (2,3) and trained sportsmen (4,5). Similarly, in patients with hypertension who are on beta-blockers, the reduction in exercise tolerance in part could be attributable to be secondary to these drugs (6). In the study by Kokkinos et al. (1), both the exercise duration and the total metabolic equivalents achieved were significantly lower in the group on beta-blockers compared to other medications. In the ASCOT–BPLA (Anglo-Scandinavian Cardiac Outcome Trial–Blood Pressure Lowering Arm) study of 19,257 patients with hypertension and at least three other coronary risk factors but no coronary artery disease, atenolol-based treatment resulted in a 14% higher risk of coronary events and a 23% increase in stroke rate compared to amlodipine-based regimen (7). In a recent meta-analysis of 134,000 patients on antihypertensive therapy, beta-blocker treatment was associated with a 16% higher incidence of stroke compared to other antihypertensive treatments (8). Of note, beta-blockers have recently been shown to differ in their effect on central aortic BP compared to peripheral brachial pressure. The Conduit Artery Functional Endpoint (CAFÉ trial) and other studies have documented that beta-blockers have a lesser effect on central systolic pressure than do angiotensin-converting enzyme (ACE) inhibitors, diuretics, and calcium antagonists (9–11). In fact, results of the CAFÉ (12) study show that a calcium antagonist–based treatment is much more effective at reducing central aortic BP than is a conventional atenolol-based (beta-blocker) regimen. Importantly, the study also suggests that the central aortic BP may be more predictive of cardiovascular events, such as stroke and myocardial infarction, than traditional peripheral (brachial) BP measurements (12).
We believe, therefore, that a conclusion, such as the above, based on peripheral BP measurements may be inappropriate. For hypertensive patients engaging in "vigorous activities," we do need a medication that curtails their (central) BP rise but not one that curtails their activity.
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References
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- Kokkinos P, Chrysohoou C, Panagiotakos D, Narayan P, Greenberg M, Singh S. Beta-blockade mitigates exercise blood pressure in hypertensive male patients J Am Coll Cardiol 2006;47:794-798.[Abstract/Free Full Text]
- Folgering H, van Bussel M. Maximal exercise power after a single dose of metoprolol and of slow-release metoprolol Eur J Clin Pharmacol 1980;18:225-229.[CrossRef][ISI][Medline]
- Wilmore JH, Freund BJ, Joyner MJ, et al. Acute response to submaximal and maximal exercise consequent to beta-adrenergic blockade: implications for the prescription of exercise Am J Cardiol 1985;55:135D-141D.[CrossRef][Medline]
- Anderson RL, Wilmore JH, Joyner MJ, et al. Effects of cardioselective and nonselective beta-adrenergic blockade on the performance of highly trained runners Am J Cardiol 1985;55:149D-154D.[CrossRef][Medline]
- Vanhees L, Fagard R, Lijnen P, Amery A. Effect of antihypertensive medication on endurance exercise capacity in hypertensive sportsmen J Hypertens 1991;9:1063-1068.[ISI][Medline]
- Lim PO, MacFadyen RJ, Clarkson PB, MacDonald TM. Impaired exercise tolerance in hypertensive patients Ann Intern Med 1996;124(1 Pt 1):41-55.[Abstract/Free Full Text]
- Dahlof B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial–Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial Lancet 2005;366:895-906.[CrossRef][ISI][Medline]
- Lindholm LH, Carlberg B, Samuelsson O. Should beta-blockers remain first choice in the treatment of primary hypertension?A meta-analysis. Lancet 2005;366:1545-1553.[CrossRef][ISI][Medline]
- London GM, Marchais SJ, Guerin AP, Pannier B. Arterial stiffness: pathophysiology and clinical impact Clin Exp Hypertens 2004;26:689-699.[CrossRef][ISI][Medline]
- Morgan T, Lauri J, Bertram D, Anderson A. Effect of different antihypertensive drug classes on central aortic pressure Am J Hypertens 2004;17:118-123.[CrossRef][ISI][Medline]
- Hirata K, Vlachopoulos C, Adji A, O’Rourke MF. Benefits from angiotensin-converting enzyme inhibitor ‘beyond blood pressure lowering’: beyond blood pressure or beyond the brachial artery? J Hypertens 2005;23:551-556.[ISI][Medline]
- Williams B, Lacy PS, Thom SM, et al. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomesPrincipal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation 2006;113:1213-1225.[Abstract/Free Full Text]
Related Article
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Reply
- Peter F. Kokkinos, Steven Singh, and Puneet Narayan
J. Am. Coll. Cardiol. 2006 48: 1285.
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