The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy. Relative value of beta blockers and thiazides for initiating antihypertensive therapy. Beta blockers or thiazides in hypertension. [Atenolol and bisoprolol in the treatment of mild and moderately severe hypertension]. Adjunctive sympathoplegic therapy to ACE inhibition in Blacks with congestive heart failure: a comparison of alpha-1 with beta-1 blockade on exercise tolerance and cardiac sympathovagal reflex activity. The Losartan Intervention For Endpoint reduction (LIFE) in Hypertension study: rationale, design, and methods. The LIFE Study Group. Beneficial effects of switching from beta-blockers to nebivolol on the erectile function of hypertensive patients. South African hypertension guideline 2011. Antihypertensive efficacy and side effects of three beta‐blockers and a diuretic in elderly hypertensives: a report from the STOP‐Hypertension study
OBJECTIVE To provide up date d , evidence -based recommendations for the prevention and management of hypertension in adults . OPTIONS AND OUTCOMES For lifestyle and pharmacological interventions , evidence was review ed from r and omized controlled trials and systematic review s of trials . Changes in cardiovascular morbidity and mortality were the primary outcomes of interest . However , for lifestyle interventions , blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field . For treatment of patients with kidney disease , the progression of kidney dysfunction was also accepted as a clinical ly relevant primary outcome . EVIDENCE A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to up date the 2006 Canadian Hypertension Education Program recommendations . In addition , reference lists were scanned and experts were contacted to identify additional published studies . All relevant articles were review ed and appraised independently by both content and method ological experts using prespecified levels of evidence . RECOMMENDATIONS Dietary lifestyle modifications for prevention of hypertension , in addition to a well-balanced diet , include a dietary sodium intake of less than 100 mmol/day . In hypertensive patients , the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day . Other lifestyle modifications for both normotensive and hypertensive patients include : performing 30 min to 60 min of aerobic exercise four to seven days per week ; maintaining a healthy body weight ( body mass index of 18.5 kg/m2 to 24.9 kg/m2 ) and waist circumference ( less than 102 cm in men and less than 88 cm in women ) ; limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women ; following a diet reduced in saturated fat and cholesterol , and one that emphasizes fruits , vegetables and low-fat dairy products , dietary and soluble fibre , whole grains and protein from plant sources ; and considering stress management in selected individuals with hypertension . For the pharmacological management of hypertension , treatment thresholds and targets should take into account each individual 's global atherosclerotic risk , target organ damage and any comorbid conditions : blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease . Most patients require more than one agent to achieve these blood pressure targets . In adults without compelling indications for other agents , initial therapy should include thiazide diuretics ; other agents appropriate for first-line therapy for diastolic and /or systolic hypertension include angiotensin-converting enzyme ( ACE ) inhibitors ( except in black patients ) , long-acting calcium channel blockers ( CCBs ) , angiotensin receptor blockers ( ARBs ) or beta-blockers ( in those younger than 60 years of age ) . First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs . Certain comorbid conditions provide compelling indications for first-line use of other agents : in patients with angina , recent myocardial infa rct ion , or heart failure , beta-blockers and ACE inhibitors are recommended as first-line therapy ; in patients with cerebrovascular disease , an ACE inhibitor plus diuretic combination is preferred ; in patients with nondiabetic chronic kidney disease , ACE inhibitors are recommended ; and in patients with diabetes mellitus , ACE inhibitors or ARBs ( or , in patients without albuminuria , thiazides or dihydropyridine CCBs ) are appropriate first-line therapies . All hypertensive patients with dyslipidemia should be treated using the thresholds , targets and agents outlined in the Canadian Cardiovascular Society position statement ( recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease ) . Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy . Once blood pressure is controlled , acetylsalicylic acid therapy should be considered . VALIDATION All recommendations were grade d according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence -Based Recommendations Task Force . All recommendations reported here achieved at least 95 % consensus . These guidelines will continue to be up date d annually Fifty-five patients with mild to moderate , renal or essential hypertension were admitted to a double blind cross-over trial of 18 weeks , involving treatment periods with placebo , the thiazide bendrofluazide ( 15 mg daily ) and the beta blocker atenolol ( 600 mg daily ) . Compared to the placebo period ( 190/117 mm Hg ) the hypotensive effect of atenolol ( -24/16 mm Hg ) was more pronounced than the hypotensive effect of bendrofluazide ( -17/6 mm Hg ) . Arguments in favor of initiating antihypertensive drug therapy with beta blocker were its more powerful hypotensive effect , the quicker onset of its action , less metabolic disturbance , decreased frequency of complaints and patient 's preference . On thiazides body weight and the frequency of swollen ankles decreased . Plasma renin concentration was not found to have a strong predicting power for the hypotensive effect of atenolol or bendrofluazide but low renin patients showed a more pronounced blood pressure decrease on bendrofluazide and high renin patients , especially essential hypertensives , on atenolol . While these points can be a guide to therapy today , the preference of one drug over the other must eventually be based on their relative efficacy in decreasing morbidity and mortality from the hypertensive disease Atenolol and bisoprolol , two beta-1-selective blockers , were compared in patients with mild and medium severe hypertension . Forty patients with a diastolic blood pressure of 95 - 115 mm Hg were two weeks after discontinuation of treatment divided at r and om into two groups treated with 50 mg atenolol and 5 mg bisoprolol . If the blood pressure was not affected by this dosage , the dose was raised to 100 mg atenolol and 10 mg bisoprolol . The blood pressure readings , heart rate , side effects of the drugs , laboratory and echocardiographic values were followed up for a period of three months . The authors recorded a marked decline of pressure and heart rate after the first week of therapy , the pressure readings in an upright position did not differ statistically from values in a sitting position , orthostatic hypotension was not recorded . The rate of success of bisoprolol was 85 % , of atenolol 75 % . During treatment no serious side-effects were observed . The biochemical parameters and echocardiographic values were not altered significantly by treatment . Atenolol and bisoprolol are two effective beta-1-selective blockers with a comparable effect in the treatment of mild and medium severe hypertension . They are useful in monotherapy as well as in combination with other antihypertensive drugs . In hypertension associated with diabetes mellitus , incipient bronchopulmonary disease and pregnancy they are also indicated . They are well tolerated also by elderly patients , an advantage of bisoprolol may be that it has a smaller impact on pressure and heart rate during the night OBJECTIVES Congestive heart failure ( CHF ) is characterized by an initial compensatory , but subsequently deleterious , activation of both the renin-angiotensin ( RAS ) and the sympathetic nervous system ( SNS ) . Incomplete suppression of the SNS may contribute to the residual mortality during optimal ACE inhibitor therapy in CHF . Carvedilol , a mixed alpha and beta-blocker with antioxidant properties , and other pure beta-adrenoceptor blockers reduce morbidity and mortality in Caucasians with CHF . However , beta-blocker monotherapy is of poor efficacy in Blacks with essential hypertension or in the treatment of glaucoma . The efficacy of beta-blockers in the treatment of African Americans with congestive heart failure is a controversial issue with conflicting findings . The aims of the present study were to examine and compare the cardiovascular , autonomic , and clinical effects of additional alpha-1 , or beta-1 blockade in ACE-inhibitor treated Black patients with moderate to severe CHF . METHODS Twenty-eight Nigerian patients with chronic CHF stabilized on digoxin and diuretics , were r and omized to 3 groups of similar demographics according to a single blind , parallel group design . The patients were aged 53 + /- 6 years , and comprised 14 men and 14 women , with a mean cardiothoracic ratio of 0.66 + /- 0.03 , and ejection fraction of 0.38 + /- 0.10 , 60 % hypertensive etiology . Group 1 patients received 5 mg enalapril alone , group 2 received 5 mg enalapril + 1 mg prazosin , and group 3 received 5 mg enalapril + 50 mg atenolol . All medication was taken daily for 4 weeks . Blood pressure , heart rate , pressure rate product , 6-minute walk test , NYHA class , and cardiac autonomic reflexes were measured at baseline and again at 2 and 4 weeks of treatment . Two-way repeated measures ANOVA , and a one-way ANOVA were used in data analysis . RESULTS The 3 treatments caused significant ( P<.001 ANOVA ) and similar improvements for the NYHA class ( -1.0 to -1.6 ) , and increased the 6-minute distance covered ( + 130 m to + 205 m ) . Although no treatment differences were observed , a trend suggesting a greater improvement with  enalapril + atenolol  became apparent . By the fourth week , the sympathoplegic treatments , enalapril + atenolol , and enalapril + prazosin , caused significant reductions in the pressure rate product ( -3726 + /- 1885 mm Hg x beats/min ; -3498 + /- 396 mm Hg beats/min , respectively ) , ( compared to enalapril alone ( -1349 + /- 894 mm Hg x beats/min ) ( P<.001 ANOVA ) . During the Valsalva maneuver , the phase IV bradycardia were significantly greater after treatment with enalapril + atenolol ( 944 + /- 66 msec ) or with enalapril + prazosin ( 825 + /- 48 msec ) , compared to enalapril alone ( 760 + /- 45 msec ) ( P<.001 ANOVA ) . The phase II Valsalva tachycardia were similar between treatments . The respiratory sinus arrhythmia ratio increased significantly ( P<.005 ANOVA ) and equally on all treatments . However , the pressor and chronotropic responses to forearm isometric h and grip increased significantly on the enalapril + prazosin combination ( P<.02 ) , compared to the other treatments . CONCLUSIONS Our findings demonstrated not only the safety of providing additional therapy with alpha-1 or beta-1 receptor blockade concurrent with ACE inhibition in Blacks with CHF , but also the result ant improvement in exercise tolerance and NYHA class . Compared to using ACE inhibition alone , the combined therapies caused a marked reduction in the pressure rate product , an index of myocardial oxygen consumption , and a greater enhancement of cardiac parasympathetic activity . Selective beta-1 blockade caused a greater enhancement of central baroreceptor vagal activity compared to alpha-1 blockade . Conversely , the pressor and chronotropic abnormalities during forearm isometric h and grip in CHF , were normalized by alpha-1 , but not beta-1 , blockade . Thus , the combined reflex cardiac vagal augmentation following selective beta-1 blockade , and the hemodynamic effects of alpha-1 antagonism with concurrent ACE inhibition , may be of major therapeutic and prognostic benefit in Blacks with non-ischemic ( hypertensive ) CHF stabilized on digoxin and diuretics The treatment of hypertension mainly with diuretics and beta blockers reduces cardiovascular mortality and morbidity , largely due to a decreased incidence of stroke , whereas the beneficial effects of antihypertensive therapy on the occurrence of coronary events have been less than expected from epidemiological studies . Furthermore , treated hypertensive patients still have a higher cardiovascular complication rate , compared with matched normotensives . This is particularly evident in patients with left ventricular hypertrophy ( LVH ) , a major independent risk indicator for cardiovascular disease . In addition to elevating blood pressure , angiotensin II ( A-II ) exerts an important influence on cardiac structure and function , stimulating cell proliferation and growth . Thus , to further reduce morbidity and mortality when treating hypertensive patients , it may be important to effectively block the effects of A-II . This can be achieved directly at the A-II receptor level by losartan , the first of a new class of antihypertensive agents . It therefore seems pertinent to investigate whether selective A-II receptor blockade with losartan not only lowers blood pressure but also reduces LVH more effectively than current therapy , and thus improves prognosis . The Losartan Intervention For Endpoint reduction ( LIFE ) in Hypertension study is a double-blind , prospect i ve , parallel group study design ed to compare the effects of losartan with those of the beta-blocker atenolol on the reduction of cardiovascular morbidity and mortality in approximately 8,300 hypertensive patients ( initial sitting diastolic blood pressure 95 to 115 mm Hg or systolic blood pressure 160 to 200 mm Hg ) with electrocardiographically documented LVH . The study , which will continue for at least 4 years and until 1,040 patients experience one primary endpoint , has been design ed with a statistical power that will detect a difference of at least 15 % between groups in the incidence of combined cardiovascular morbidity and mortality . It is also the first prospect i ve study with adequate power to link reversal of LVH to reduction in major cardiovascular events . The rationale of the study , which will involve more than 800 clinical centers in Sc and inavia , the United Kingdom , and the United States , is discussed , and the major features of its design and general organization are described . On April 30 , 1997 , when inclusion was stopped , 9,218 patients had been r and omized AIM To investigate the effect of substituting beta-blockers with nebivolol on the  erectile function of patients suffering from essential hypertension . METHODS Forty-four young and middle-aged men ( 31 - 65 years ) with essential hypertension visited our outpatient clinic and took beta-blocker treatment  ( atenolol , metoprolol or bisoprolol )  for more than 6 months . All the patients completed a question naire regarding erectile function ( International Index for Erectile Function ) . Patients were then switched to an equipotent dose of nebivolol for 3 months and , at the end of this time period , filled out the same question naire . RESULTS Twenty-nine out of the 44 ( 65.9 % ) patients who took beta-blockers ( atenolol , metoprolol or bisoprolol ) had exhibited erectile dysfunction ( ED ) . Their systolic and diastolic blood pressure did not change significantly with the treatment switch . In 20 out of these 29 ( 69 % ) patients , a significant improvement in the erectile function score was exhibited after 3 months of nebivolol administration , and in 11 of these 20 patients , erectile function was normalized . CONCLUSION Nebivolol seems to have a beneficial effect on ED ( possibly due to increased nitric oxide availability ) ; however , further prospect i ve , r and omized , placebo-controlled studies are needed to confirm the beneficial effects of nebivolol OUTCOMES Extensive data from r and omised controlled trials have shown the benefit of treating hypertension . The target blood pressure ( BP ) for antihypertensive management is systolic < 140 mmHg and diastolic < 90 mmHg with minimal or no drug side-effects ; however , stricter BP control is required for patients with end-organ damage , co-existing risk factors and co-morbidity , e.g. diabetes mellitus . The reduction of BP in the elderly and in those with severe hypertension should be achieved gradually over 1 month . Co-existent risk factors should also be controlled . BENEFITS Benefits of management include reduced risks of stroke , cardiac failure , chronic kidney disease and coronary heart disease . RECOMMENDATIONS The correct BP measurement procedure is described , and evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated . The total cardiovascular disease risk profile should be determined for all patients to inform management strategies . Lifestyle modification and patient education are cornerstones in the management of every patient . Major indications , pre caution s and contra-indications to each recommended antihypertensive drug are listed . Combination therapy should be considered ab initio if the BP is ≥ 20/10 mmHg . First-line drug therapy for uncomplicated hypertension includes low-dose thiazide-like diuretics , calcium channel blockers ( CCBs ) or angiotensin-converting enzyme inhibitors ( ACE-Is ) ( or ARBs - angiotensin II receptor blockers ) . If the target BP is not obtained , a second antihypertensive should be added from the aforementioned list . If the target BP is still not met , the third remaining antihypertensive agent should be used . In black patients  either thiazide-like diuretics or CCBs can be used initially , because response rates are better than with ACE-Is or β-blockers . In treating resistant hypertension , a central ly acting drug , vasodilator , α-blocker , spironolactone or β-locker should be added . This guideline includes management of specific situations , i.e. hypertensive emergency and urgency , severe hypertension with target organ damage , hypertension in diabetes mellitus , resistant hypertension , fixed drug combinations , new trials in hypertension , and interactions of antihypertensive agents with other drugs . VALIDITY The guideline was developed by the Southern African Hypertension Society Objective : To compare the blood pressure‐lowering efficacy , the frequency of side effects and changes in laboratory values of three & bgr;‐blockers and a potassium‐sparing diuretic combination in elderly hypertensive patients . Design : The Swedish Trial in Old Patients with Hypertension ( STOP‐Hypertension ) was a prospect i ve , r and omized , double‐blind , multicentre trial comparing active antihypertensive treatment with placebo in patients aged 70‐84 years . Methods : The study group consisted of 1627 elderly hypertensive patients ( mean ± SD age 75.7 ± 3.7 years ; 37 % males , 63 % females ) . Supine and st and ing blood pressure , heart rate and side effects were recorded at each visit . Blood was drawn for routine analysis . The mean length of follow‐up was 25 months ( range 6‐65 ) . No patient was lost to follow‐up . Results : After 2‐months ' single‐drug therapy , all four active drugs were found to be equally effective in reducing diastolic blood pressure ( DBP ) . However , there were differences in their efficacy in reducing systolic blood pressure ( SBP ) ; the diuretic was significantly more effective than the & bgr;‐receptor blockers . The results of a series of multiple linear regression analyses showed that the observed differences in effect on SBP could not be explained by the different effects of the drugs on heart rate . More than two‐thirds of the patients were given supplementary treatment , most of them already by the 2‐month visit , after which there was no significant difference in blood pressure among the treatment regimens . The changes in laboratory values and in the prevalence of symptoms were minor for all four regimens . Conclusion : Metoprolol ( controlled release ) , atenolol , pindolol and the combination hydrochlorothiazide + amiloride were equally effective as single drugs in reducing DBP . There were differences in their efficacy in reducing SBP , the diuretic being more effective than the & bgr;‐blockers . After addition of supplementary treatment ( & bgr;‐blocker to diuretic , or vice versa ) there were no significant differences in blood pressure reduction among the groups . The changes in laboratory values and in the prevalence of symptoms were minor for all active treatment regimens . Thus , the satisfactory effect on cardiovascular morbidity and mortality was not impaired by low tolerability of the drugs
SBP-lowering effects were significantly increased for bisoprolol compared with placebo .
In conclusion , current evidence does not support carvedilol or bisoprolol as first-line therapy for adult hypertension without compelling indications
Although beta blockers have been used as initial therapy for ischemic heart diseases and heart failure , the beneficial effects of beta blockers are controversial compared with other antihypertensive agents as initial therapy for hypertension without compelling indications .
Moreover , atenolol has been most commonly used with beta blockers .
The objective of the present systematic review associated with the Japanese Society of Hypertension ( JSH ) 2019 Hypertension Guideline ( Clinical Question 6 ) was to assess the outcomes ( cardiocerebrovascular mortality , total cause mortality , hypotension , bradycardia , other adverse effects , and changes in systolic blood pressure ( SBP ) ) of currently used carvedilol and bisoprolol as initial therapy for adult hypertension without compelling indications .