Hypertension Controversies

Part of the Contemporary Cardiology book series (CONCARD)


This statement is printed on the front cover of The Lancet of October 29, 2005. It is surprising that this peer-reviewed journal would print such a misleading statement.
  • The quote was based on a metaanalysis by Lindholm et al., who concluded that beta-blockers should not remain first choice in the treatment of primary hypertension and should not be used as reference drugs in future randomized controlled trials (RCTs) of hypertension (1). Unfortunately, many experts in the field have endorsed the conclusions of this faulty metaanalysis. Beta-blockers have been used for more than 35 yr for the treatment of hypertension. The controversy regarding their continued use is of paramount importance, particularly because there are more than 1 billion hypertensive individuals who require treatment, and only four classes of antihypertensive agents are available: beta-blockers, diuretics, calcium antagonists, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). The two other drug classes (alpha blockers [doxazosin] and centrally acting agents [methyldopa, clonidine]) have been rendered relatively obsolete for the management of primary hypertension (see later discussion and alpha-blocker section in Chapter 8). Methyl dopa remains useful mainly for hypertension in pregnancy.

  • In 14 studies analyzed by Lindholm et al., atenolol was the beta-blocker used; in four trials, mixtures of atenolol, metoprolol, and pindolol were used (see Table 9-1).

  • In a Lancet letter, Cruickshank stated that by lumping together all randomized hypertension trials involving beta-blockers, Lars Lindholm and colleagues have arrived at misleading conclusions (2), and I concur with this statement. This discussion reviews trials selected by Lindholm and colleagues and emphasizes that the metaanalysis suggests that atenolol is not an effective choice for the management of hypertension but does not indicate that other beta-blockers are ineffective in decreasing cardiovascular disease (CVD) morbidity and mortality associated with hypertension.


Calcium Antagonist Coronary Heart Disease Event Primary Hypertension Achieve Goal Blood Pressure Conduit Artery Function Evaluation 
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Suggested Reading

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