Practice changer
Beta-blockers should not be used to treat hypertension in patients older than age 60 unless they have another compelling indication to use these agents, such as heart failure or ischemic heart disease.1,2
Strength of recommendation
A: Based on a well-done meta-analyses
Khan N, Mcalister FA. Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis. CMAJ 2006; 174:1737– 1742.1
Wiysonge CS, Bradley H, Mayosi BM, et al. Beta-blockers for hypertension. Cochrane Database Syst Rev 2007; (1):CD002003.2
Illustrative case
A 70-year-old man with newly diagnosed hypertension comes to your office. You don’t want to prescribe a diuretic due to his history of gout. He has no history of coronary artery disease or heart failure.
What is the best antihypertensive agent for him?
Background: Guidelines do not reflect new evidence
Guidelines for the use of beta-blockers in the elderly do not reflect current evidence.
JNC recommendations
The 2003 JNC 7 Report recommended the same antihypertensive medications for adults of all ages.3 (JNC 7 is the most recent report from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.)
JNC 7 recommends thiazide diuretics for first-line treatment of hypertension, and recommends other drugs—including beta-blockers, calcium-channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs)—for first-line therapy if a thiazide is contraindicated, or in combination with thiazides for higher initial blood pressure.
Compelling indications. Beta-blockers are recommended in the JNC 7 Report as first-line therapy in patients with “compelling indications” such as ischemic heart disease and heart failure.
Clinical context: Seniors taking beta-blockers to their detriment?
Many elderly patients are on beta-blockers, perhaps to their detriment. Treatment choices for hypertension can have an enormous impact on outcomes among older patients:
Two thirds of US adults 60 years of age and older have hypertension, mostly isolated systolic hypertension.4,5
Multiple studies, including the Systolic Hypertension in the Elderly Program and the Systolic Hypertension in Europe, have shown that lowering blood pressure with pharmacologic interventions in older patients can reduce the risk of cardiovascular events and possibly dementia.6
Beta-blockers have been a mainstay of hypertension treatment for many decades and we suspect continue to be widely used as first-line therapy in patients for whom the evidence now indicates they are inferior.
Heart failure and angina are indications for beta-blockers
New evidence does not alter the 2003 JNC 7 recommendations to use beta-blockers as first-line therapy in patients with “compelling indications” such as ischemic heart disease and heart failure.
Study summaries
Two well-done reviews of beta-blocker trials show that they are inferior for first-line hypertension treatment in the elderly who do not have heart failure or angina.
2007 Cochrane review
The 2007 Cochrane review2 analyzed randomized trials that compared beta-blockers for hypertension in adults 18 years of age and older to each of the other major classes of antihypertensives.
Conclusion. This meta-analysis showed a “relatively weak effect of beta-blockers to reduce stroke, and the absence of effect on coronary heart disease when compared with placebo or no treatment” and a “trend toward worse outcomes in comparison with calcium channel blockers, renin-angiotensin system inhibitors, and thiazide diuretics.”
This meta-analysis included all adults and did not make any conclusions based on age.
2006 CMAJ meta-analysis
The Kahn and McAlister meta-analysis1 pooled data from 21 randomized hyper-tension trials (including 6 placebo-controlled trials) that evaluated the efficacy of beta-blockers as first-line therapy for hypertension in preventing major cardiovascular outcomes (death, nonfatal MI, or nonfatal stroke).
The results were analyzed by age group: trials enrolling patients with a mean age of 60 years or older at baseline vs trials enrolling patients with a mean age of under 60 years.
Conclusion. They concluded that in trials comparing other antihypertensive medications with beta-blockers, all agents showed similar efficacy in younger patients, while in older patients, beta-blockers were associated with a higher risk of both composite events and strokes ( TABLE ).
TABLE
Adverse outcomes more likely in seniors taking a beta-blocker vs other antihypertensives1
| ADVERSE OUTCOME | PATIENTS UNDER AGE 60 | PATIENTS AGE 60 AND OVER |
|---|---|---|
| ADVERSE OUTCOMES LESS LIKELY WITH A BETA-BLOCKER | ADVERSE OUTCOMES MORE LIKELY WITH A BETA-BLOCKER | |
| Composite outcomes (death, stroke, or MI) | RR=0.97 (95% CI, 0.88–1.07) | RR=1.06 (95% CI, 1.01–1.1) |
| Stroke | RR=0.99 (95% CI, 0.67–1.44) | RR=1.18 (95% CI, 1.07–1.3) |
| RR, relative risk of adverse outcomes, in randomized clinical trials of hypertensive patients treated with beta-blockers, compared with other antihypertensive drugs. | ||
