A Future of Beta Blockers “Plus” to Treat Hypertension

[zkt]

http://www.consultantlive.com/conference-reports/ash2013/content/article/10162/2143139

A Future of Beta Blockers “Plus” to Treat Hypertension?
By Gregory W. Rutecki, MD | May 20, 2013
Dr Rutecki is Professor of Internal Medicine at the University of South Alabama in Mobile.

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In my previous article, A Requiem for Beta Blockers to Treat Hypertension?, I described the current move away from beta blocker therapy for hypertension as discussed by speakers at the 2013 ASH annual meeting. This included key points about what has changed between JNC 7 (beta blockers a viable early option for treatment) and data considered for JNC 2013.

Following are some more of the key points, including a discussion of so-called beta blockers “plus.”

1. Why have the efficacy and safety profiles of beta blockers and angiotensin receptor blockers (ARBs) changed? Much of the data reviewed in my earlier article was obtained in an era that did not include prompt revascularization, statins, antiplatelet therapies, and angiotensin-converting enzyme inhibitors/ARBs. The new era of hypertension management considered by JNC 2013 and the National Institute for Clinical Excellence committee has proven that beta blocker benefits may have been strictly limited to a demographic “gone by” that did not have access to interventional expertise.

For example, patients enrolled in the REACH Registry (n=44,708; JAMA, 2012; 308:1340), which addressed beta blockade in persons with prior myocardial infarctions (MIs), known coronary disease, and significant risk factors for coronary disease. Cardioprotection within these 3 groups was no different with or without beta blockers. What worked yesterday has become obsolete. The ALLHAT study reached similar conclusions.

2. Other data add to the persisting concerns regarding beta blockers and their purported cardioprotection. In ASCOT-LLA, patients treated with atorvastatin(Drug information on atorvastatin)/placebo were compared with those treated with atorvastatin and beta blockade. Significant end points were better in the statin-placebo group compared with statin-beta blockers. The results suggest that beta blockers interfere with important statin pleiotropic effects essential to cardioprotection. Earlier studies suggesting beta blocker benefits preceded statins.
3. Unbelievers quote the mantra that it is blood pressure lowering per se and not the agent used that is important. This observation is only true based on ALLHAT. The primary end points in ALLHAT were no different with similar blood pressure lowering with 3 antihypertensives. However, the 3 agents were chlorthalidone, amlodipine(Drug information on amlodipine), and lisinopril(Drug information on lisinopril). There were no beta blockers used in this study. All antihypertensives are not created equally! Similar blood pressure reductions achieved by beta blockers are not the same as those consequent to the agents used in ALLHAT.

4. Far and away the majority of studies determining the negatives of beta blockers were performed with atenolol(Drug information on atenolol). This particular beta blocker is more suspect than any other. Studies have demonstrated that it raises central blood pressure (the pressure experienced by the heart, kidneys, and brain) despite lowering brachial pressure. This paradoxical effect is a bad one. A meta-analysis of atenolol versus other antihypertensives found a risk ratio of 1.26 for all events with atenolol as opposed to other agents.

5. The prior hallowed ground for beta blockers was not hypertension, but rather post-MI protection. The INVEST trial compared verapamil(Drug information on verapamil) with beta blockers in this role. Verapamil was noninferior to atenolol in all aspects except that atenolol increased the risk of stroke.

6. On to beta blockers “plus.” The term means that beta blockade is accompanied by other important actions. Carvedilol(Drug information on carvedilol) also provides alpha-blocking effects. Nebivolol(Drug information on nebivolol) also provides nitric oxide generation. As a result of the “plus” portion, for example, nebivolol does not increase central blood pressure. The caveats surrounding beta blockers in general, and especially atenolol, do NOT apply to beta blocker plus agents!

JNC 2013 is right around the corner. I do not have a crystal ball, and speakers at ASH could only speculate, but it looks like the beta blocker era for treating blood pressure will be limited to beta blockers plus.

 

[LW64]

Very informative!

Thanks, zkt.

 

[Dr JIM]

Most doctors, my self included, consider Beta blockers 4th line behind, diuretics, ABRs and Ca blockers.

This is particularly true in MALES since BB increase SD considerably and the dysfunction is almost guaranteed at "upper end dosages"

Thx
Z

 

[zkt]

Very informative!

Thanks, zkt.

I want some of this stuff.
Not only beta selective but nitric oxide (NO)-potentiating. My dick loves nitric oxide. LOL.
I`m also going to stop the metroprolol and see if the bronchial spasms improve.
The crdiac stress test is next week. I somehow managed to miss it the first two times. Talk about who`s driving the bus!
[ame=http://en.wikipedia.org/wiki/Nebivolol]Nebivolol - Wikipedia, the free encyclopedia[/ame]

 

[biceps72]

Most doctors, my self included, consider Beta blockers 4th line behind, diuretics, ABRs and Ca blockers.

This is particularly true in MALES since BB increase SD considerably and the dysfunction is almost guaranteed at "upper end dosages"

Thx
Z

SORRY- got lost
what is SD?
What are ABRS?

where do ACE inhibitors fit into this scheme?

thanks

Big

 

[Michael Scally MD]

IIRC, beta blockers are great for "passing" lie detector exams.

 

[zkt]

SD: no clue; stadard deviation?
ARB= angiotensin receptor blocker
ACE and ARB are quite similar in action. ACE inhibits the enzyme that converts angiotensin type one to type two. ABR blocks the AT2 receptor. The whole thing involves the RAS ( renin angiotensinogin system) and gets fairly complicated.
ACE/ARB are usually quite effective but must be used with caution in cases of renal impaiorment. Hyperkalemia often results, which is why I dont use them myself. However careful doseage titration may avoid the problem.

SORRY- got lost
what is SD?
What are ABRS?

where do ACE inhibitors fit into this scheme?

thanks

Big

 

[LW64]

I believe SD is sexual dysfunction...Dr. Jim can verify...

 

[zkt]

I believe SD is sexual dysfunction...Dr. Jim can verify...

Oh !, I forgot about that since starting trazadone. LOL ( iwish, it seems that the 5ht2a receptor has up regulated leaving the situation essentially the same as befor starting it.)
As it turns out ADC has nebivolol at a very reasonable price. Even beats the VA copay. So we will see if the purported nitric oxide potentiating effects has an effect on the SD.

 

[Michael Scally MD]

Maraj I, Makaryus JN, Ashkar A, McFarlane SI, Makaryus AN. Hypertension Management in the High Cardiovascular Risk Population. International Journal of Hypertension. 2013:7. Hypertension Management in the High Cardiovascular Risk Population

The incidence of hypertension is increasing every year. Blood pressure (BP) control is an important therapeutic goal for the slowing of progression as well as for the prevention of Cardiovascular disease. The management of hypertension in the high cardiovascular risk population remains a real challenge as the population continues to age, the incidence of diabetes increases, and more and more people survive acute myocardial infarction. We will review hypertension management in the high cardiovascular risk population: patients with coronary heart disease (CHD) and heart failure (HF) as well as in diabetic patients.

 

[zkt]

There is no doubt whatsoever in that. More ever, HT is a fairly easy problem to treat altho a lot of GPs arent up to speed IMHO. Controling BP is especially important in cases where HT is due to renal artery stenosis. Actually the most important aspect in preserving kidney function as well as prolonging a healthy life.

 

[Dr JIM]

Z

ABRs is a typo for ARBs = angiotensin receptor blockers

SD = Sexual Dysfunction (FYI: I prefer the term SD over ED since many patients with SD don't have ED.)

Regarding ACE inhibitors vs ARBs. The primary difference is cost, because the majority of ACEIs are available in generic form. However many patients have minimal or no response to an ACEI yet will respond remarkably well to an ARB, especially when a diuretic is added, MYSELF included.

At present I begin with a diuretic and will add either an ACE or an ARB depending upon what the patient can afford.

That being said their are some articles which contend one may be preferred over the other especially for patients with either Nephropathy or CHF, but I believe it's to early to say, since truly comparative studies are to few.

Best
jim

 

[zkt]

Excellent points Jim. TY.
The lack of understanding among some GPs I refered to certainly doesnt apply to you.
.Much of my dealing with GPs involves residents or freshly out of residency practioners at the VA.

"At present I begin with a diuretic and will add either an ACE or an ARB depending upon what the patient can afford. "

A doctor who takes cost into consideration!
Thats unheard of.!
Are you sure you are a real doctor? lol. [)]

 

[Dr JIM]

No drug is beneficial if patients won't take them regardless of their reasoning.

Moreover I train residents on a daily basis so am familiar with what your speaking of about younger DOCS.

Did you know at least 90% of PCP lawsuits occur in their first five years of practice and trickles to about ZERO shortly thereafter?

Hey have you ever talked to a drug rep who doesn't know a damn thing about the drugs he's selling? I prefer Meso as would you, lol!

Experience definitely matters in medicine like most other professions.

 

[CensoredBoardsSuck]

No drug is beneficial if patients won't take them regardless of their reasoning.

Moreover I train residents on a daily basis so am familiar with what your speaking of about younger DOCS.

Did you know at least 90% of PCP lawsuits occur in their first five years of practice and trickles to about ZERO shortly thereafter?

Hey have you ever talked to a drug rep who doesn't know a damn thing about the drugs he's selling? I prefer Meso as would you, lol!

Experience definitely matters in medicine like most other professions.

Excellent point Dr Jim. It's been my experience that recent graduates in any discipline, especially medicine, are nothing more than scholars of trivia. They've been given the tools of the trade, but don't really learn to use them until they're on the job and under the tutelage of a journeyman. Every profession is still an apprenticeable trade.

Be careful what you say about drug reps, though - you might not get your free pen. Then people won't be able to complain about the kickbacks you doctors get from Big Pharma.

 

[idmd]

No drug is beneficial if patients won't take them regardless of their reasoning.

Moreover I train residents on a daily basis so am familiar with what your speaking of about younger DOCS.

Did you know at least 90% of PCP lawsuits occur in their first five years of practice and trickles to about ZERO shortly thereafter?

Hey have you ever talked to a drug rep who doesn't know a damn thing about the drugs he's selling? I prefer Meso as would you, lol!

Experience definitely matters in medicine like most other professions.

Is that because they make fewer mistakes or because they shed their residency attitude and learn how to talk to people?

In dentistry there is a steep learning curve between residency (Medicaid patients who have no other choice than you) vs private practice (people who have choices and only stay if they like you).

People tend to not file against doctors they like.....learning how to talk to people takes time and reduces law suits.

 

[CensoredBoardsSuck]

Is that because they make fewer mistakes or because they shed their residency attitude and learn how to talk to people?

What is "their residency attitude?" The nonsense they're taught about how to empathize with and relate to the patient? I can see how that artificiality would put patients off. I certainly don't like.

People tend to not file against doctors they like.....learning how to talk to people takes time and reduces law suits.

Good point.

I also think sometimes inexperienced doctors tend to underestimate their patients ability to understand. The Pt might not understand the details of the procedure or the technical jargon but they can instinctively tell whether the doctor is experienced and knows what he's doing. It seems to me, they would be more likely to sue a doctor they think is clueless but nice, rather than one more skilled but gruff. JMHO

 

[idmd]

What is "their residency attitude?" The nonsense they're taught about how to empathize with and relate to the patient? I can see how that artificiality would put patients off. I certainly don't like.



Good point.

I also think sometimes inexperienced doctors tend to underestimate their patients ability to understand. The Pt might not understand the details of the procedure or the technical jargon but they can instinctively tell whether the doctor is experienced and knows what he's doing. It seems to me, they would be more likely to sue a doctor they think is clueless but nice, rather than one more skilled but gruff. JMHO

Residency attitude = the chip on the shoulder caused by having to be both inexperienced and work in a hospital full of piranha. It is my experience (I completed two hospital-based residencies and spent many nights in the ED, 3 months doing GA in the OR and rotated through many departments) that bed-side skills get better in private practice.

My comment about patients not suing doctors they like is not my idea - father-in-law in a medical malpractice defense attorney in NYC with 40 years experience - that's what he says.

 

[Dr JIM]

When a relative dies unexpectedly or sustains a lifelong disability, (strike AMI, aneurysm) which could encumber others, people want answers. It typically matters not who they "like" but whom they know and trust certainly makes a difference, IME.

What percent of med-mal cases go to trial ~ 1%

What percent have an award settlement 10-20%

What percent are outrightly dismissed 80-90%

( The data varies CONSIDERABLY state by state. The East and West coast states have some of the highest dollar amounts and a percentage of in/out court settlements)

How many med-mal cases have been filed against Jim
THREE all in the first three years post residency.

What was the result? 2 dismissed and one was "settled for 8K".

Jim

 

[idmd]

Well he's adamant that likable doctors are sued less than unlikable. Furthermore, he's defended and lost cases to brilliant doctors who did nothing wrong but were assholes far more often than likable dopes who actually screwed up.

Personally I have no idea (never sued)....just sharing 13 years of conversation with someone who does it daily.