Concerning the degradation of β-blocker use in the 2018 ESC/ESH hypertension guidelines

This commentary refers to ‘2018 ESC/ESH Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH)’, by B. Williams et al., 2018;39:3021–3104. We disagree with the exclusion of β-blockers (BBs) as initial treatment of uncomplicated hypertension in the 2018 European Hypertension Guidelines,1 because the limitations of the old atenolol (the BB used in most prior studies) cannot be extrapolated to the newer BBs, and might bring about premature curtailment in the use of these agents in general. More precisely, one of the main limitations of the evidence-based methods employed was the unwarranted extrapolation of results using one medication to the rest in its class, and BBs constitute one of the most heterogeneous class of antihypertensive medications.1 Other points arguing against the exclusion of BB are: Atenolol was used suboptimally in clinical trials such as LIFE (Losartan Intervention For Endpoint reduction in hypertension) and ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial),1 because it was used once per day, rather than the optimal, more frequent dosing; atenolol’s half-life is only 6–7 h, leaving patients unprotected during critical nighttime and early morning periods.2 There is no evidence against atenolol use (concerning blood-pressure variability, central blood pressure, and stroke incidence) when used twice per day. One of the systems participating in the genesis of hypertension and cardiovascular risk is the sympathetic nervous system, and it could be most relevant in younger patients or people with a high heart rate.1 , 3 BBs may be more effective in patients with hypertension who are younger than 60 years.3 Resting heart rate >80 b.p.m. is often regarded as a practical surrogate for adrenergic activation and increased cardiovascular risk.1 Most hypertensive patients require two or more drugs to achieve blood pressure control, and early use of antihypertensive therapy and combinations of these drugs are emerging strategies for controlling hypertension.1 Hence, the concern about what antihypertensive drug should be used first becomes less urgent. Most clinical trials have combined atenolol with diuretics, but there is no evidence against using BBs in combination with other antihypertensive drugs.1 BBs are part of the World Health Core list of medicines required for implementing essential cardiovascular disease interventions in primary care, and availability of key drugs in low-income and middle-income countries remains a concern.4 It is in the low-income and middle-income European countries, where therapy utilization needs to be scaled-up most, that all inexpensive modalities must be in supply.5 The availability and affordability of other antihypertensive drugs, such as an angiotensin receptor blockers, could be poor for low-moderate income European individuals. In conclusion, BBs should also be considered in Steps 1–2 of the core drug treatment strategy for uncomplicated hypertension, especially in younger patients without a diuretic. Conflict of interest: none declared.