Beta-blockers for Hypertension: To Be or Not to Be a First-line Drug?

Nobel laureate Sir James Black pioneered the concept and design of beta-blockers for cardiovascular use. The first human data published on beta-blockers appeared in 1964, and ever since, beta-blockers have been widely utilized across various cardiovascular conditions. In hypertension, the landmark Medical Research Council (MRC) trial was the first to demonstrate that either propranolol or bendrofluazide reduced the risk of stroke in patients with mild hypertension; however, no significant reduction in mortality was observed. Comparative analyses between propranolol and bendrofluazide showed similar outcomes, with a non-significant trend favoring bendrofluazide for stroke prevention and propranolol for coronary event reduction in non-smokers.

Historically, beta-blockers became a mainstay in hypertension management. In 1984, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC III) classified beta-blockers alongside thiazide diuretics as first-line therapy. In 1998, Messerli et al. published a systematic review questioning the appropriateness of beta-blockers as first-line agents, concluding that in elderly hypertensive patients, beta-blockers were inferior to diuretics in reducing cardiovascular outcomes.

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