Key result
Atenolol linked to ~14% higher risk of major events versus amlodipine despite similar BP reduction.
Why the study?
Cardioselective beta-blockers like atenolol are widely used in hypertension, but their indication as first-line therapy remains controversial.
Does atenolol reduce major cardiovascular events compared to other first-line antihypertensive drugs in adults with primary hypertension?
Systematic Review (n=59,788)
Does atenolol reduce major cardiovascular events compared to other first-line antihypertensive drugs in adults with primary hypertension?
Atenolol provides similar blood pressure reduction but slightly worse cardiovascular outcomes compared to other first-line antihypertensives, supporting its use primarily as combination therapy rather than first-line monotherapy.
Supports preferring amlodipine or losartan over atenolol for first-line hypertension therapy; confirms inferior cardiovascular outcomes despite equivalent BP reduction.
BACKGROUND: Hypertension (HTN) is a global public health issue, with high prevalence and a significant impact on cardiovascular morbidity and mortality. Cardioselective beta-blockers, such as atenolol, are widely used in the treatment of HTN, although their indication as first-line therapy remains controversial. OBJECTIVE: To evaluate the efficacy and safety of atenolol in the treatment of primary HTN, compared with other first-line classes of antihypertensive drugs. METHODS: A systematic review was conducted based on a research question structured using the PICO format. Randomized clinical trials comparing atenolol with other antihypertensive agents were included. Searches were performed in three international databases. Methodological quality was assessed using the RoB 2 tool, and the certainty of evidence was rated using the GRADE system. The primary composite outcome was the occurrence of major cardiovascular events. Secondary outcomes included all-cause mortality, acute myocardial infarction, and stroke, each analyzed separately. RESULTS: Seven clinical trials met the inclusion criteria. Compared with amlodipine and losartan, atenolol was associated with a slightly higher incidence of cardiovascular events, with low and moderate certainty of evidence, respectively. The combination of hydrochlorothiazide and amiloride demonstrated a greater reduction in cardiovascular events compared to atenolol, although with very low certainty of evidence. Blood pressure (BP) reduction was similar across the compared treatments. CONCLUSIONS: Despite the limitations of available evidence, atenolol showed comparable efficacy in BP reduction, with small differences in cardiovascular outcomes favoring other antihypertensive classes. Its use may be considered among the options for combination therapy in the treatment of primary HTN in adults. Other beta-blockers were not evaluated in this systematic review.
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Brandão et al. (2025) conducted a systematic review in Primary Hypertension (n=59,788). Atenolol vs. Other first-line antihypertensive classes (amlodipine, losartan, hydrochlorothiazide + amiloride, captopril, lacidipine, verapamil, placebo/standard) was evaluated on Major cardiovascular events (composite of all-cause mortality, stroke, and acute myocardial infarction) (OR 1.14, 95% CI 1.05-1.23). Atenolol was associated with a slightly higher incidence of major cardiovascular events compared to amlodipine (OR 1.14) and losartan (OR 1.18), despite demonstrating similar efficacy in blood pressure reduction.
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