Journal of Hypertension | 2021
Reply.
Abstract
W e read with interest the letter of Stoschitzky [1] on our systematic review and meta-analysis on betablockers in hypertension [2]. We would like to clarify that according to our findings, beta-blockers are protective against fatal and nonfatal cardiovascular events (triple composite major cardiovascular outcomes) and that in this setting, the beta-blocker-related protection was not different compared with all other antihypertensive drug classes. This is the reason why several guidelines for the management of hypertension, including the latest European Society of Cardiology and European Society of Hypertension guidelines, correctly indicate that beta-blockers should form, together with all other main classes of antihypertensive drugs, the basis of antihypertensive therapy. The statement of the JNC VI guidelines that antihypertensive treatment should be started with diuretics and betablockers in patients with uncomplicated hypertension was a wise guidance to clinicians based on the information available at that time, that is, in 1997 before the era of the trials comparing different antihypertensive agents (including beta-blockers) and showing in most instances, the similarity of their protective effect. As atenolol was used in the vast majority of beta-blocker trials, the results of metaanalyses of nonatenolol beta-blocker trials are limited both by a very-low statistical power and by a great imprecision in the averaged risk estimates (i.e. wide confidence intervals). We agree with Stoschitzky [1] that the third-generation betablockers demonstrate a neutral metabolic profile compared with the first-generation or second-generation beta-blocking agents, which scores in favour of the use of these newer drugs. However, randomized outcome trials with nebivolol and carvedilol are limited to heart failure [3,4], and thus, their protective effect in hypertension remains untested or suggested by observational studies in which nebivolol was compared with the second-generation beta-blockers, atenolol, and metoprolol [5]. In all guidelines, this is a limitation to their preferential use.