Should β blockers no longer be considered first-line therapy for the treatment of essential hypertension without comorbidities?

Although most guidelines committees historically recommended initial diuretics and/or β blockers for uncomplicated hypertension, clinical trial outcomes analyzed in the last 5 to 7 years have been suboptimal with atenolol, the world's most popular β blocker. Several meta-analyses have suggested that despite lowering blood pressure, any and all β blockers inadequately protect hypertensive patients from cardiovascular events. These phenomena have been attributed to ineffective lowering of central aortic or inter-visit blood pressures, or adverse metabolic effects (particularly when combined with diuretics). Although there has never been a head-to-head comparison of atenolol with any other β blocker in hypertensive patients, indirect comparisons can be done with network and Bayesian meta-analyses, which suggest that heterogeneity of β-blockers' pharmacology also extends to outcomes. Although once-daily atenolol as initial antihypertensive therapy may be unwise, whether initial β blockers newer than atenolol reduce cardiovascular risk to the same extent as other antihypertensive drugs should be answered with more clinical trials.