Should β-Blockers Be Used to Treat Hypertension in Elderly Patients?—Reply

In Reply: While it is true that both β-blockers and diuretics are recommended by JNC VI, the report states, "When compared with each other, diuretics (hydrochlorothiazide with amiloride hydrochloride) are superior to the β-blocker atenolol. In older patients with isolated systolic hypertension, diuretics are preferred because they significantly reduce multiple end-point events."¹ One reason diuretics may be superior is that a major pathological component of hypertension in the elderly is decreased arterial compliance, which leads to a selective increase of systolic pressure as a result of accelerated reflection of the arterial pulse wave from the periphery.² Peripheral resistance is increased, and cardiac output is low. β-Blockade lowers cardiac output; furthermore, in younger patients with systolic hypertension, acute β-blockade lowers blood pressure without affecting arterial compliance, whereas in older patients, compliance is decreased and blood pressure is unchanged.³ In elderly patients with systolic hypertension, diuretic treatment lowers peripheral resistance without affecting cardiac output.⁴ Thus, there are theoretical as well as practical reasons for believing that diuretic treatment is preferable to treatment with β-blockers in elderly patients with uncomplicated hypertension.