A Modern Perspective on β‐Blocker Use in Hypertension: Clinical Trials and Their Influence on Clinical Practice

National guidelines recommend β‐blockers as second step agents after diuretic therapy in patients without compelling indications despite little clinical trial evidence of cardiovascular outcome benefits in uncomplicated essential hypertension. In high‐risk patients with hypertension, such as those with a previous myocardial infarction or diabetes, heart failure, or coronary artery disease, β‐blockers have been shown to reduce the risk of cardiovascular mortality and to reduce events beyond those ascribed to blood pressure (BP) lowering. The use of a β‐blocker‐based regimen in patients with diabetes has been shown to reduce cardiovascular mortality, progression of diabetic nephropathy, and stroke. Lowering BP in hypertensive patients is a primary goal, but it is also essential that goal BP be achieved with the fewest adverse consequences (ie, by choosing agents that do not worsen concomitant conditions or cause unacceptable side effects). Physicians must consider issues of possible worsening insulin resistance and dyslipidemia associated with some β‐blockers. These metabolic concerns, however, are not an issue for the combined β‐/αblocker carvedilol. This review highlights historical data and important clinical trials that underscore the importance of β‐blockade in specific patients and delineates situations where β‐blockers benefit patients with hypertension and/or cardiovascular disease.