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For Debate: The 2023 European Society of Hypertension guidelines - cause for concern
Eduard Shantsila1,2, D Gareth Beevers3, Gregory Y H Lip2,4
1Department of Primary Care and Mental Health, University of Liverpool.
Insights
Beta-blockers are less effective for stroke prevention compared to other hypertension drugs, as shown in major trials. Current guidelines favoring their use are concerning and warrant reconsideration for patient safety.
Area of Science:
- Cardiovascular Medicine
- Pharmacology
- Hypertension Management
Background:
- Beta-blockers were initially considered equivalent to other antihypertensive drug classes.
- Landmark trials like ASCOT-BPLA and LIFE revealed significant increases in stroke risk with beta-blocker regimens.
Purpose of the Study:
- To analyze the clinical inferiority of beta-blockers in stroke prevention.
- To evaluate the implications of the 2023 European Society of Hypertension (ESH) guidelines regarding beta-blocker use.
Main Methods:
- Review and analysis of data from major long-term randomized controlled trials (ASCOT-BPLA, LIFE).
- Examination of the 2023 European Society of Hypertension (ESH) guidelines.
- Comparative analysis of stroke incidence and blood pressure control across different antihypertensive drug classes.
Main Results:
- Patients on beta-blocker regimens experienced 25-30% more strokes than those on calcium channel blocker or angiotensin receptor blocker regimens.
- This inferiority in stroke prevention was independent of blood pressure control differences.
- The 2023 ESH guidelines continue to advocate for beta-blockers, attributing inferiority to lesser blood pressure reduction, not a class effect.
Conclusions:
- The re-emergence of beta-blockers as a first-line hypertension treatment by ESH guidelines is a significant concern.
- The clinical inferiority of beta-blockers in stroke prevention necessitates a reconsideration of their role in uncomplicated hypertension management.
- Further research and guideline revision are crucial to ensure optimal patient outcomes in hypertension therapy.
Abstract:
Originally, the beta-blockers were equally ranked alongside the other antihypertensive drug classes. Things changed when two major long-term randomized controlled trials, ASCOT-BPLA and LIFE showed that the patients receiving the beta-blockers based regimes suffered 25-30% more strokes than those receiving a calcium channel blocker based regime or an angiotensin receptor blocker based regime. The inferiority of the beta-blockers at stroke prevention was not due to differences in blood pressure control during the follow-up period in both trials. The 2023 European Society of Hypertension (ESH) guidelines still argue in favour of beta-blockers that their clinical inferiority was simply to lesser blood pressure reduction rather than class effect. The analysis argues that the return of beta-blockers as a first-line option for the management of uncomplicated hypertension by the ESH is a cause for concern and should be reconsidered.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.