β-blockers as the First Line of Treatment for Hypertension Management

β-adrenergic blocker group of medicines has been traditionally used to control high blood pressure since propranolol was discovered by Sir James Black almost 50 years ago. They were the drug of choice in hypertension (HTN) associated with ischemic heart disease, tachyarrhythmias including atrial fibrillation (AF), and anxiety. Congestive cardiac failure was a relative contraindication, but with major advances in science, it became an absolute indication. However, with the advent of newer antihypertensives, especially calcium channel blocker (CCBs) and renin-angiotensin-aldosterone inhibitors, comparative studies were done, and depending on the outcomes of these trials, β-blockers (BBs) were downgraded to fourth or fifth-line therapy, except in the conditions mentioned above, along with HTN in pregnancy. But clinicians never rejected BBs as important antihypertensives, as evidenced by various real-world data. Also, many investigators found the unfairness of the trial designs where BBs were poor performers. The fact that all BBs are not similar, and differ widely in various properties, added to the question of downgrading all BBs on the basis of trials mostly with atenolol, which is also used once daily. Moreover, trials like ASCOT could not show the reduction of most of the events after long-term follow-up with the use of newer antihypertensives. Added to the issue is the fact that the majority of the trials used BBs with diuretics, and selecting BBs as the sole nonperformer appears to be unjustified and illogical. The recent European Society of HTN (ESH) guideline reemphasized the fact that all the five major classes of antihypertensives, including BBs, can be used as first-line medicine and also can be used interchangeably. Moreover, apart from the traditional indications of BBs, this guideline listed nineteen other conditions, including high heart rate (HR), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnoea, as the conditions where BBs are preferred agents as antihypertensive. So, the life history of BBs in HTN has completed a full cycle, and they are ready now for prime time again. How to cite this article: Ray S, Saboo B, Joshi S, et al. β-blockers as the First Line of Treatment for Hypertension Management. J Assoc Physicians India 2023;71(9):95-100.