Revisiting the role of beta blockers in the management of hypertension

PURPOSE OF REVIEW: Although beta blockers have a long history in hypertension management, their first-line role remains controversial after early-2000 s trials raised concerns about inferior stroke prevention with traditional beta-blocker based regimens. This review re-examines the role of beta blockers in contemporary hypertension care by integrating mechanistic insights, phenotype-oriented considerations, and recent clinical evidence. RECENT FINDINGS: Recent randomized controlled trials in acute myocardial infarction suggest that beta blocker depends on patient selection and left ventricular ejection function, arguing against routine use. Advances in out-of-office blood pressure (BP) assessment have enabled identification of clinically relevant phenotypes - including BP variability, morning BP surge, and nocturnal hypertension - that are closely linked to sympathetic overactivity and elevated heart rate. These associated pathophysiological abnormalities provide a mechanistic rationale for targeted beta-blocker use. Moreover, beta blockers are a heterogeneous drug class; β1-selective and vasodilatory agents exhibit distinct hemodynamic effects, including on central hemodynamics. SUMMARY: Beta blockers should not be viewed as universally applicable antihypertensive agents; instead, they are best positioned as phenotype-oriented therapies for selected patients with heightened sympathetic activity, specific BP phenotypes, or coexisting cardiovascular disease. Contemporary evidence supports an individualized approach that moves beyond legacy beta-blocker-based regimens toward selective beta-blocker use in modern cardiovascular care.