B-blockers not first line in systolic hypertension

B-blockers are not appropriate first-line therapy for elderly patients with isolated systolic hypertension, it was reported at a conference sponsored by the American College of Cardiology.

A surprising number of physicians have mistakenly extrapolated form the well-known guideline in the sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-VI), which highlights diuretics and B-blockers as the initial drugs of choice for uncomplicated hypertension in younger patients. JNC-VI specifically identifies diuretics and long-acting dihydropyridine calcium channel blockers – not B-blockers – as the initial agents of choice for uncomplicated hypertension in younger patients. JNC-VI specifically identifies diuretics and long-acting dihydropyridine calcium channel blockers – not B-blockers – as the initial agents of choice in isolated systolic hypertension in older patients, according to professor of medicine at Stanford California University.

B-blockers have never shown to reduce mortality in patients with coronary or vascular disease unless they have had an MI. If you disagree with the statement bring me the reference.

The JNC-VI recommendation to initiate therapy with a diuretic or a dihydropyridine calcium channel blocker in patients with isolated systolic hypertension is based upon compelling clinical trial data that show an association with marked reductions in overall mortality, cardiovascular events and stroke.

The Systolic Hypertension-Europe (Syst-Eur) trial, for example, documented a 31 percent reduction in all cardiovascular end points with calcium channel blocker therapy, compared with placebo, during two years of follow-up in a randomized study of 4,700 patients over age 60 witih isolated systolic hypertension. In a Syst-Eur sub study of 429 diabetic patients with isolated systolic hypertension, the dihydropyridine calcium channel blocker resulted in a 63 percent reduction in cardiac events, a 73 percent decrease in strokes, and a 76 percent drop in mortality due to cardiovascular disease.

In the 4,736-patients Systolic Hypertension in the Elderly Program (SHEP), a chlorthalidone-based stepped-care regimen for isolated systolic hypertension resulted in a 32 percent reduction in total major cardiovascular events during five years of follow-up. If you look at the drugs that are most effective for (inducing regression of) left ventricular hypertrophy, it’s the calcium channel blockers and ACE inhibitors. B-blockers are the worst.

So if you believe that left ventricular hypertrophy is an independent cardiovascular risk factor and reflects blood pressure control, it’s another reason not to use B-blockers, the cardiologist said. In terms of patient adherence – a critical consideration in lifelong management of a silent chronic disease such as hypertension – studies demonstrate that diuretics fare worst in terms of patient compliance and B-blockers are fair. Calcium channel blockers and ACE inhibitors do best in terms of patient adherence because they have the least bothersome side effects.