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Are β-Blockers Efficacious as First-line Therapy for Hypertension in the Elderly?  A Systematic Review

Franz H. Messerli, MD; Ehud Grossman, MD; Uri Goldbourt, PhD
JAMA. 1998;279(23):1903-1907. doi:10.1001/jama.279.23.1903.
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Objective.— To assess antihypertensive efficacy of β-blockers and their effects on cardiovascular morbidity and mortality and all-cause morbidity compared with diuretics in elderly patients with hypertension.

Data Source.— A MEDLINE search of English-language articles published between January 1966 and January 1998 using the terms hypertension (drug therapy) and elderly or aged or geriatric, and cerebrovascular or cardiovascular diseases, and morbidity or mortality. References from identified articles were also reviewed.

Data Selection.— Randomized trials lasting at least 1 year, which used as first-line agents diuretics and/or β-blockers, and reported morbidity and mortality outcomes in elderly patients with hypertension.

Data Synthesis and Results.— Ten trials involving a total of 16164 elderly patients (≥60 years) were included. Two thirds of the patients assigned to diuretics were well controlled on monotherapy, whereas less than a third of the patients assigned to β-blockers were well controlled on monotherapy. Diuretic therapy was superior to β-blockade with regard to all end points and was effective in preventing cerebrovascular events (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.51-0.72), fatal stroke (OR, 0.67; 95% CI, 0.49-0.90), coronary heart disease (OR, 0.74; 95% CI, 0.64-0.85), cardiovascular mortality (OR, 0.75; 95% CI, 0.64-0.87), and all-cause mortality (OR, 0.86; 95% CI, 0.77-0.96). In contrast, β-blocker therapy only reduced the odds for cerebrovascular events (OR, 0.75; 95% CI, 0.57-0.98) but was ineffective in preventing coronary heart disease, cardiovascular mortality, and all-cause mortality (ORs, 1.01, 0.98, and 1.05, respectively).

Conclusions.— In contrast to diuretics, which remain the standard first-line therapy, β-blockers, until proven otherwise, should no longer be considered appropriate first-line therapy of uncomplicated hypertension in the elderly hypertensive patient.

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Figure 1.—Meta-analysis of prospective clinical trials in elderly patients with hypertension according to first-line treatment strategy.
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Figure 2.—Morbidity and mortality in Medical Research Council trial in older adults. Data modified with permission from Lever and Brennan.19



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