Rationale for the Inclusion of β-Blockers Among Major Antihypertensive Drugs in the 2023 European Society of Hypertension Guidelines

Author:

Mancia Giuseppe1ORCID,Brunström Mattias2ORCID,Burnier Michel3ORCID,Grassi Guido4ORCID,Januszewicz Andrzej5,Kjeldsen Sverre E.67ORCID,Muiesan Maria Lorenza8ORCID,Thomopoulos Costas9ORCID,Tsioufis Konstantinos10ORCID,Kreutz Reinhold11ORCID

Affiliation:

1. University Milano-Bicocca, Milan, Italy (G.M.).

2. Department of Public Health and Clinical Medicine, Umea University, Sweden (Mattias Brunström).

3. Faculty of Biology and Medicine, University of Lausanne, Switzerland (Michel Burnier).

4. Clinica Medica, University Milano-Bicocca, Milan, Italy (G.G.).

5. Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.J.).

6. Institute for Clinical Medicine, University of Oslo, Norway (S.E.K.).

7. Departments of Cardiology and Nephrology, Ullevaal Hospital, Oslo, Norway (S.E.K.).

8. UOC 2 Medicina, ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy (M.L.M.).

9. Department of Cardiology, General Hospital of Athens “Laiko”, Greece (C.T.).

10. First Department of Cardiology, Medical School, University of Athens, Hippokration Hospital, Greece (K.T.).

11. Charite-Universitaetsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Germany (R.K.).

Abstract

We address the reasons why, unlike other guidelines, in the 2023 guidelines of the European Society of Hypertension β-blockers (BBs) have been regarded as major drugs for the treatment of hypertension, at the same level as diuretics, calcium channel blockers, and blockers of the renin-angiotensin system. We argue that BBs, (1) reduce blood pressure (the main factor responsible for treatment-related protection) not less than other drugs, (2) reduce pooled cardiovascular outcomes and mortality in placebo-controlled trials, in which there has also been a sizeable reduction of all major cause-specific cardiovascular outcomes, (3) have been associated with a lower global cardiovascular protection in 2 but not in several other comparison trials, in which the protective effect of BBs versus the other major drugs has been similar or even greater, with a slightly smaller or no difference of global benefit in large trial meta-analyses and a similar protective effect when comparisons extend to BBs in combination versus other drug combinations. We mention the large number of cardiac and other comorbidities for which BBs are elective drugs, and we express criticism against the exclusion of BBs because of their lower protective effect against stroke in comparison trials, because, for still uncertain reasons, differences in protection against cause-specific events (stroke, heart failure, and coronary disease) have been reported for other major drugs. These partial data cannot replace global benefits as the main deciding factor for drug choice, also because in the general hypertensive population whether and which type of event might occur is unknown.

Publisher

Ovid Technologies (Wolters Kluwer Health)

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