Antihypertensive Therapy: Beta-Blockers and Diuretics—Why Do Physicians Not Always Follow Guidelines?

Abstract

The most recent reports of the Joint National Committee (JNC VI) and the World Health Organization recommend beta-blockers and diuretics as first-line therapy for uncomplicated essential hypertension (1, 2). Similar recommendations have been issued over the past few years by many authoritative sources and influential journals. These recommendations were supposedly based on multiple prospective randomized trials attesting that only beta-blockers and diuretics, both in monotherapy and in combination, reduced morbidity and mortality in hypertension. Ever since the Veterans Administration study in the 1970s (3), multiple and prospective randomized trials have documented that diuretic-based therapy reduces the risk of stroke and, to a lesser extent, of heart attacks and cardiovascular morbidity and mortality. However, the data are much less convincing for beta-blockers (4). In fact, no trial has shown that lowering blood pressure with a beta-blocker reduces the risk of a heart attack or cardiovascular event in patients with essential hypertension compared with placebo. In contrast, several prospective studies are now available showing that blood pressure reduction with calcium antagonists diminishes cardiovascular morbidity and mortality and, at least in meta-analysis, all-cause mortality. Moreover, recent data showing that the long-term use of diuretics increases the risk of renal cell carcinoma (RCC) threw a shadow on the bright picture of diuretics as reducers of cardiovascular morbidity and mortality in hypertension (5). Clearly, not all patients with essential hypertension are ideal candidates for long-term exposure to diuretic therapy. In the following, I present some caveats for the sweeping recommendations to use beta-blockers and diuretics as “preferred” antihypertensive therapy in the majority of patients.