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Hypertension in the elderly: a compelling contraindication for β-blockers?

Journal of Human Hypertension volume 21, pages 259–260 (2007)Cite this article

The study by Tu et al.1 published in this issue of the Journal of Human Hypertension is an eye opener for those of us who were under the impression that β-blocker prescriptions in elderly hypertensive patients had diminished. This pharmaco-epidemiologic study looks at actual β-blocker prescriptions and its trend from 1994 to 2002 in elderly hypertensive patients who had no compelling indication for a β-blocker. Although the study has inherent limitations because it uses administrative data, it gives insight into the ‘real world’ of the prescription pattern for β-blockers and shows that in Ontario an alarming one in 10 elderly hypertensive patients are prescribed a β-blocker. This is despite the Canadian Recommendations for the Management of Hypertension published in 1999, which states ‘Although β-adrenergic antagonists may be useful as adjunctive therapy in elderly patients taking diuretics, they are not recommended as first-line therapy (grade A)’.2 We had published a year earlier, a meta-analysis of randomized trials lasting ⩾1 year and which used a diuretic, a β-blocker, or both as first-line therapy; and reported morbidity and mortality in the elderly (>60 years).3 Analysis of the 10 trials involving 16 164 elderly patients suggested a distinct difference in the antihypertensive efficacy between the two therapeutic strategies: whereas hypertension was controlled in 66% of patients assigned to diuretics monotherapy, it was controlled in less than one-third of patients on β-blocker monotherapy.3 Despite this meagre blood pressure control with β-blocker monotherapy, the dropout rate was twice as high in the β-blocker group compared with the diuretic group and β-blockers were ineffective in preventing coronary heart disease and cardiovascular and all-cause mortality (odds ratio, 1.01, 0.98 and 1.05, respectively).3 It is somewhat ironic that even after more than three decades of using β-blockers for hypertension, no study has yet shown that their monotherapeutic use has reduced morbidity or mortality in hypertensive patients compared with placebo.

The prescription pattern in Canada showed a steady increase in the number of β-blocker prescription for elderly hypertensive despite national guideline recommendations to the contrary and despite lack of evidence supporting their use. Does this mean that Canadians do not follow guidelines or data published in the literature? An analysis of the prescription pattern of Spironolactone for chronic heart failure in Ontario showed a 338% increase in the prescription rate immediately following the publication of the Randomized Aldactone Evaluation Study (RALES) in the US with an associated increase in hyperkalemia-associated morbidity and mortality.4 Similarly after the publication of the Heart Outcomes Prevention Evaluation (HOPE) trial there was an exponential increase in the use of ramipril compared to other angiotensin converting enzyme inhibitors in Canada. This clearly suggests that Canadian physicians do closely follow the literature. A closer look at the studies on β-blockers published between 1998 and 1999 shows that several pivotal studies attesting to the beneficial effects of β-blockers were published during that time period. Metoprolol XL Randomized Intervention Trial in Heart Failure (MERIT-HF), the largest heart failure trial ever completed showed a clear reduction in mortality in patients on β-blockers compared to placebo, was published in 1999.5 Several other studies attesting to the efficacy of β-blockers in patients with myocardial infarctions6, 7, 8 and in high-risk patients undergoing non-cardiac surgery9 were published in the same period. Other national and international guidelines continued their endorsement for the use of β-blockers in hypertension.10, 11 It is therefore not surprising that physicians in Canada and elsewhere continued prescribing β-blockers for hypertension. In a recent meta-analysis of 105 951 patients, β-blockers resulted in a 16% higher incidence of stroke and no benefit for the end point of myocardial infarction in comparison with other antihypertensive agents including thiazide diuretics12 attesting to and expanding on our observation made more than half a decade earlier.

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  1. Department of Medicine, Division of Cardiology, St Luke's-Roosevelt Hospital and Columbia University, New York, NY, USA

    S Bangalore & F H Messerli

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Correspondence to F H Messerli.

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Bangalore, S., Messerli, F. Hypertension in the elderly: a compelling contraindication for β-blockers?. J Hum Hypertens 21, 259–260 (2007). https://doi.org/10.1038/sj.jhh.1002144

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