Beta-blockers in patients with uncomplicated arterial hypertension: data from the Campania Salute Network Registry

Background The role of beta-blockers in the management of uncomplicated arterial hypertension remains a subject of clinical debate. While beta-blockers are established cornerstones for heart failure and post-myocardial infarction care, their independent efficacy in reducing major adverse cardiovascular events (MACE) in patients without these compelling indications is less clear. Aim This study aimed to evaluate the association between beta-blocker use and MACE in a real-world hypertensive population without prevalent cardiovascular diseases. Methods We analyzed 6,702 hypertensive patients from the Campania Salute Network (CSN) registry (median age 53 years, 43% females, 9% with diabetes, 25% with obesity) without prevalent coronary or cerebrovascular disease, valvular heart disease, or heart failure. The association between beta-blocker use and MACE was assessed using three statistical approaches: multivariable-adjusted Cox proportional hazards regression, propensity score matching (PSM), and overlap weighting (OW). An intention-to-treat (ITT) analysis was performed based on baseline prescription, and a per-protocol (PP) sensitivity analysis was conducted to evaluate the role of sustained treatment adherence. Results At baseline, 18.1% (n=1,247) of patients were receiving a beta-blocker. Over a median follow-up of 52 months, 308 MACE (4.5%) occurred. After multivariable adjustment, PSM, and OW, beta-blocker use was not associated with a lower risk of MACE in the ITT population (Adjusted hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.86-1.52; PSM HR 1.18, 95% CI 0.82-1.70; OW HR 1.10, 95% CI 0.82-1.46) (Figure 1). In the per-protocol sensitivity analysis, even among adherent patients, beta-blocker therapy was not associated with a lower risk of MACE (Figure 2). Conversely, adherence to renin-angiotensin system inhibitors and statins was associated with significantly lower risk of MACE (HR for renin-angiotensin system inhibitors 0.80, 95% CI 0.66-0.98; HR for statins 0.28, 95% CI 0.11-0.70). Beta-blocker users also exhibited a higher prevalence of metabolic risk factors, including elevated triglycerides, glycemia, and uric acid levels. Conclusions In patients with uncomplicated hypertension, beta-blocker use was not associated with a lower MACE risk, regardless of treatment adherence. These findings reinforce modern clinical guidelines that prioritize non-beta-blocker-based regimens and suggest the use of beta-blockers in the presence of specific compelling indications.