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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses the use of beta-blockers in the treatment of hypertension. Also discussed are the LIFE, ASCOT-LLA, ASCOT-BPLA, and ASCOT-CAFE trials, as well as European Society of Hypertension\/European Society of Cardiology hypertension guidelines.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ehypertensive disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EBeta-Blockers: No Longer Preferred Therapy in Hypertension\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003E\u201cNewer drugs, especially in combination, have advantages over beta-blockers,\u201d said Adrian J.B. Brady, MD, Glasgow Royal Infirmary, Glasgow, Scotland.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EIn several analyses of the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) trial, losartan-based therapy was better than atenolol-based therapy for a range of outcomes, including atrial fibrillation (AF) (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Wachtell K et al. \u003Cem\u003EJACC\u003C\/em\u003E 2005]. The superiority of losartan over atenolol in AF was a surprising finding, given that beta-blockade has historically been recommended as first-line therapy to prevent AF and it is the preferred treatment for rate-control in established AF [Fuster V et al. \u003Cem\u003EJACC\u003C\/em\u003E 2001].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022LIFE: New-Onset Atrial Fibrillation.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1242439344\u0022 data-figure-caption=\u0022LIFE: New-Onset Atrial Fibrillation.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10901\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ELIFE: New-Onset Atrial Fibrillation.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReprinted from \u003Cem\u003EJACC\u003C\/em\u003E, Wachtell K et al, copyright 2005, with permission from the American College of Cardiology.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EIn the Anglo-Scandinavian Cardiac Outcomes Trial - Lipid Lowering Arm (ASCOT-LLA), benefits associated with atorvastatin therapy in the amlodipine group were not observed in the atenolol group. In ASCOT-LLA, patients randomized to amlodipine or atenolol in the main ASCOT trial were further randomized to atorvastatin (n=5,168) or placebo (n=5,137). Among patients in the amlodipine group, atorvastatin reduced coronary heart disease (CHD) events by 53% (p\u0026lt;0.0001). In contrast, atorvastatin did not provide significant protection against CHD events in the atenolol group. Differences in blood pressure and lipid parameters between the amlodipine and atenolol treatment arms could not account for the differences in CHD outcome [Sever PS et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003E\u201cWhen we are treating multiple risk factors, such as hypertension and hyperlipidemia, beta-blockers may not be the preferred therapy for these individuals,\u201d Prof. Brady said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EBeyond blood pressure-lowering, Prof. Brady emphasized the importance of other physiological effects when considering the benefits of different antihypertensive agents. Implications of these other physiological effects were illustrated when patients in the ASCOT-Blood Pressure Lowering (ASCOT-BPLA) arm were matched for blood pressure at several time points across the study. Creating a large cohort of patients with the same blood pressure allowed researchers to identify whether different agents produced different clinical outcomes beyond blood pressure-lowering. Compared with those in the atenolol group, patients in the amlodipine group had a 13% lower risk of all-cause mortality and coronary revascularization (HR 0.87; p=0.0177) and a 17% lower risk for fatal and nonfatal stroke (HR 0.83; p=0.0147) that was unaccounted for by improvements in blood pressure alone [Poulter NR et al. \u003Cem\u003ELancet\u003C\/em\u003E 2005].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EProf. Brady noted that different antihypertensive agents have different effects on central blood pressure. Indeed, another subanalysis of ASCOT, the Conduit Artery Function Evaluation (ASCOT-CAFE) trial, demonstrated that different antihypertensive agents can have substantially different effects on central aortic pressures and hemodynamics despite similar impacts on brachial blood pressure. In ASCOT-CAFE, patients in the amlodipine and atenolol treatment arms had similar brachial systolic blood pressures, with an average difference of 0.7 mm Hg between groups (p=0.2). Despite this similarity, patients in the amlodipine group had significantly greater reductions in central aortic pressures, including central aortic systolic blood pressure (4.3 mm Hg; p\u0026lt;0.001) and central aortic pulse pressure (3.0 mm Hg; p\u0026lt;0.0001), compared with the atenolol group.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EDifferences in central pressure have major clinical implications. In ASCOT-CAFE, central pulse pressure was significantly associated with the composite endpoint of total cardiovascular events and procedures and development of renal impairment (p\u0026lt;0.05, adjusted for baseline variables) [Williams B et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2006]. This finding provides further support for the idea that beta-blockers lack important cardioprotective features present in other antihypertensive agents, Prof. Brady said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe movement away from beta-blockers as preferred blood pressure agents is reflected in the updated hypertension guidelines published by the National Institute for Health and Clinical Excellence (NICE) and the British Health Service. Based on recent data favoring other antihypertensive agents, beta-blockers are no longer preferred as a routine first-line therapy for hypertension. Instead, beta-blockers are recommended as a fourth option behind ACE inhibitors, calcium channel blockers, and thiazide-type diuretics.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EBeta-Blockers: Still Valuable Therapy in Hypertension\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003ETaking the opposing view, Bj\u00f6rn Dahl\u00f6f, MD, PhD, University of G\u00f6teborg, Sweden, argued in his presentation that beta-blockers still play an important role in the treatment of hypertension.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003E\u201cOne of the reasons we have been unsuccessful in treating hypertension is that we have not agreed on first-line therapy in the guidelines,\u201d Prof. Dahl\u00f6f said. As examples, he pointed to the 2006 NICE guidelines and the 2007 European Society of Hypertension (ESH)\/European Society of Cardiology (ESC) hypertension guidelines (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u00222007 ESH\/ESC Guidelines: Antihypertensive drug combinations.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1242439344\u0022 data-figure-caption=\u00222007 ESH\/ESC Guidelines: Antihypertensive drug combinations.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/7\/27\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10906\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003E2007 ESH\/ESC Guidelines: Antihypertensive drug combinations.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EESH=European Society of Hypertension\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EESC=European Society of Cardiology\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReprinted with permission from \u003Cem\u003EEur Heart J\u003C\/em\u003E, Mancia G et al, copyright 2007.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EPreferred combinations for the general hypertensive population are represented as thick lines.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EFrames indicate classes of agents with proven benefits in controlled intervention trials. Whereas the 2006 NICE guidelines list beta-blockers as fourth-line agents, the 2007 ESH\/ESC hypertension guidelines position beta-blockers much more prominently [Mancia G et al. \u003Cem\u003EEur Heart\u003C\/em\u003E J 2007]. Specifically, the 2007 ESH\/ESC hypertension guidelines note:\u003C\/p\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-16\u0022\u003EThe main benefits of antihypertensive treatment are due to lowering of blood pressure per se, and are largely independent of drugs employed\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-17\u0022\u003EThiazide diuretics, beta-blockers, calcium antagonists, ACE inhibitors, and angiotensin receptor antagonists can adequately lower blood pressure and significantly and importantly reduce cardiovascular outcomes\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-18\u0022\u003EThese drugs are thus all suitable for initiation and maintenance of antihypertensive treatment as monotherapy or in combination with each other\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-19\u0022\u003EBeta-blockers are listed as favored agents in patients with previous MI, angina, permanent AF, tachyarrhythmia, and glaucoma\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EIn addition to their blood-pressure-lowering effects, beta blockers provide other cardioprotective benefits in select patient subgroups. For example, a meta-analysis of four intravascular ultrasonography trials showed that beta-blockers slow the progression of coronary atherosclerosis in patients with known coronary artery disease (n=1,515) [Sipahi I et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2007]. Therefore, beta-blockers may play an important role in overall cardiovascular risk reduction.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EAntihypertensive research is rapidly evolving, and Prof. Dahl\u00f6f acknowledged that the focus of research in blood pressure control is moving beyond traditional agents. Given the results of LIFE and other recent trials that have demonstrated the superiority of newer agents over atenolol, atenolol is no longer an appropriate reference drug for future trials of cardiovascular risk in hypertension, he said. However, he argued that beta-blockers should be judged on an individual molecular basis, adding that newer beta-blockers still have a role in hypertension research.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003E\u201cAlthough beta-blockers are no longer the preferred first-line agents in the treatment of uncomplicated hypertension, these agents still have a place in the therapeutic armamentarium,\u201d Prof. Dahl\u00f6f concluded. \u201cBeta-blockers are needed in patients with special conditions and indications.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2007 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/7\/7\/27.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzm782\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm782\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}