Prevention of risk factors: beta-blockade and hypertension

Some national guidelines on hypertension have demoted beta-blockers from a first-choice to a fourth-choice treatment. In contrast, the 2007 guidelines of the European Society of Hypertension/European Society of Cardiology (ESH/ESC) retain them among the drug classes used to initiate and maintain antihypertensive treatment, together with diuretics, angiotensin-converting enzyme (ACE)-inhibitors, calcium antagonists, and angiotensin receptor antagonists. The reasons are as follows. First, in most trials beta-blockers were used with thiazide diuretics, making it illogical to drop one and save the other. Secondly, individual trials and meta-analyses conflict regarding whether beta-blockers are less effective in preventing cardiovascular events than other drugs. Thirdly, a reduced protective effect of beta-blockers against stroke has been reported in some but not all trials; blood pressure reduction per se is probably the most important factor in protecting patients against stroke. Rationally, therefore, it seems appropriate for the ESH/ESC guidelines to recommend that no available drug class should be generically prescribed or proscribed. Beta-blockers should be avoided in patients with a high risk of incident diabetes, and in those with contraindications. However, they remain drugs of crucial importance in other common clinical situations, e.g. in hypertensive patients with angina pectoris, post-myocardial infarction, and heart failure.