Atenolol in uncomplicated hypertension: time for changes

Abstract

I read with interest the recent Article by Rothwell and colleagues,1Rothwell PM Howard SC Dolan E et al.on behalf of the ASCOT-BPLA and MRC Trial InvestigatorsEffects of beta blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke.Lancet Neurol. 2010; 9: 469-480Summary Full Text Full Text PDF PubMed Scopus (549) Google Scholar which shows the importance of blood-pressure variability as a vascular risk marker and adds new evidence against use of atenolol in uncomplicated hypertension.I would like to emphasise that new β blockers do not seem to have the same limitations as atenolol.2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar Perhaps the time has come to decide whether to let atenolol die or to try to bring it back to life in the treatment of uncomplicated hypertension. On the basis of available evidence, most clinicians would accept the first choice. However, there are several reasons to favour the second choice. First, atenolol is effective in secondary prevention of hypertension and in treatment of young people with uncomplicated hypertension.2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar Second, the availability and affordability of preventive treatments vary enormously worldwide; the availability of certain key drugs used for the treatment of chronic diseases is poor in several low-income and middle-income countries.3Joshi R Jan S Wu Y MacMahon S Global inequalities in access to cardiovascular health care: our greatest challenge.J Am Coll Cardiol. 2008; 52: 1817-1825Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar Are the same antihypertensive treatment regimens applicable in these countries as in the USA and Europe? Should atenolol be avoided as a first-line treatment in low-income countries before new antihypertensives become available? Third, most of the evidence against atenolol comes from clinical trials in which it was used once per day,2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar even though atenolol's half-life is only 18 h.4Neutel JM Schnaper H Cheung DG et al.Antihypertensive effects of beta-blockers administered once daily: 24-hour measurements.Am Heart J. 1990; 120: 166-171Summary Full Text PDF PubMed Scopus (72) Google Scholar Is there evidence against atenolol when prescribed every 12 h? Can atenolol decrease blood-pressure variability and stroke incidence when used twice per day? Fourth, most clinical trials have combined atenolol with diuretics, which can trigger adverse metabolic effects. Nevertheless, other combinations, such as atenolol and calcium channel blockers, have not been explored.2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar Finally, the effect of blood-pressure lowering drugs in reducing the risk of cardiovascular disease is largely caused by blood-pressure reduction.5Law MR Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.BMJ. 2009; (published online May 19.)https://doi.org/10.1136/bmj.b1665Crossref Scopus (2035) Google ScholarIn summary, I think that there are scientific and economic reasons to try to bring atenolol back to life in uncomplicated hypertension when prescribed every 12 h or when combined with vasodilators, or both.Thanks to Alain Escarra for English revision. I have no conflicts of interest. I read with interest the recent Article by Rothwell and colleagues,1Rothwell PM Howard SC Dolan E et al.on behalf of the ASCOT-BPLA and MRC Trial InvestigatorsEffects of beta blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke.Lancet Neurol. 2010; 9: 469-480Summary Full Text Full Text PDF PubMed Scopus (549) Google Scholar which shows the importance of blood-pressure variability as a vascular risk marker and adds new evidence against use of atenolol in uncomplicated hypertension. I would like to emphasise that new β blockers do not seem to have the same limitations as atenolol.2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar Perhaps the time has come to decide whether to let atenolol die or to try to bring it back to life in the treatment of uncomplicated hypertension. On the basis of available evidence, most clinicians would accept the first choice. However, there are several reasons to favour the second choice. First, atenolol is effective in secondary prevention of hypertension and in treatment of young people with uncomplicated hypertension.2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar Second, the availability and affordability of preventive treatments vary enormously worldwide; the availability of certain key drugs used for the treatment of chronic diseases is poor in several low-income and middle-income countries.3Joshi R Jan S Wu Y MacMahon S Global inequalities in access to cardiovascular health care: our greatest challenge.J Am Coll Cardiol. 2008; 52: 1817-1825Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar Are the same antihypertensive treatment regimens applicable in these countries as in the USA and Europe? Should atenolol be avoided as a first-line treatment in low-income countries before new antihypertensives become available? Third, most of the evidence against atenolol comes from clinical trials in which it was used once per day,2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar even though atenolol's half-life is only 18 h.4Neutel JM Schnaper H Cheung DG et al.Antihypertensive effects of beta-blockers administered once daily: 24-hour measurements.Am Heart J. 1990; 120: 166-171Summary Full Text PDF PubMed Scopus (72) Google Scholar Is there evidence against atenolol when prescribed every 12 h? Can atenolol decrease blood-pressure variability and stroke incidence when used twice per day? Fourth, most clinical trials have combined atenolol with diuretics, which can trigger adverse metabolic effects. Nevertheless, other combinations, such as atenolol and calcium channel blockers, have not been explored.2Mancia G Laurent S Agabiti-Rosei E et al.Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158Crossref PubMed Scopus (1431) Google Scholar Finally, the effect of blood-pressure lowering drugs in reducing the risk of cardiovascular disease is largely caused by blood-pressure reduction.5Law MR Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.BMJ. 2009; (published online May 19.)https://doi.org/10.1136/bmj.b1665Crossref Scopus (2035) Google Scholar In summary, I think that there are scientific and economic reasons to try to bring atenolol back to life in uncomplicated hypertension when prescribed every 12 h or when combined with vasodilators, or both. Thanks to Alain Escarra for English revision. I have no conflicts of interest. Atenolol in uncomplicated hypertension: time for changes – Author's replyWe thank Dr Morales for his comments; however, we do not agree with some of the points that he raises. First, in our systematic review of data from randomised controlled trials of blood-pressure lowering drugs, we showed that the adverse effect of β blockers on variability in blood pressure is not confined to atenolol.1 Second, the systematic review also showed that the effect of β blockers on variability in blood pressure was unrelated to the half-life of the particular β blocker studied,1 and so it is unlikely that twice-daily administration of atenolol would reduce the adverse effects. Full-Text PDF