How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Systematic review and meta-analysis

J Hypertens. 2006 Nov;24(11):2131-41. doi: 10.1097/01.hjh.0000249685.58370.28.


Objective: To quantify the effect of first-line antihypertensive treatment with beta-blockers on mortality, morbidity and withdrawal rates, compared with the other main classes of antihypertensive agents.

Methods: We identified eligible trials by searching the Cochrane Controlled Trials Register, Medline, Embase, reference lists of previous reviews, and contacting researchers. We extracted data independently in duplicate and conducted meta-analysis by analysing trial participants in groups to which they were randomized, regardless of subsequent treatment actually received.

Results: Thirteen trials with 91,561 participants, meeting inclusion criteria, compared beta-blockers to placebo (four trials; n = 23,613), diuretics (five trials; n = 18,241), calcium-channel blockers (CCBs) (four trials; n = 44,825), and renin-angiotensin system (RAS) inhibitors, namely angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (three trials; n = 10,828). Compared to placebo, beta-blockers reduced the risk of stroke (relative risk 0.80; 95% confidence interval 0.66-0.96) with a marginal fall in total cardiovascular events (0.88, 0.79-0.97), but did not affect all-cause mortality (0.99, 0.88-1.11), coronary heart disease (0.93, 0.81-1.07) or cardiovascular mortality (0.93, 0.80-1.09). The effect on stroke was less than that of CCBs (1.24, 1.11-1.40) and RAS inhibitors (1.30, 1.11-1.53), and that on total cardiovascular events less than that of CCBs (1.18, 1.08-1.29). In addition, patients on beta-blockers were more likely to discontinue treatment than those on diuretics (1.80; 1.33-2.42) or RAS inhibitors (1.41; 1.29-1.54).

Conclusion: Beta-blockers are inferior to CCBs and to RAS inhibitors for reducing several important hard end points. Compared with diuretics, they had similar outcomes, but were less well tolerated. Hence beta-blockers are generally suboptimal first-line antihypertensive drugs.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Adrenergic beta-Antagonists / adverse effects
  • Adrenergic beta-Antagonists / therapeutic use*
  • Antihypertensive Agents / adverse effects
  • Antihypertensive Agents / therapeutic use*
  • Calcium Channel Blockers / therapeutic use
  • Diuretics / therapeutic use
  • Humans
  • Hypertension / complications
  • Hypertension / drug therapy*
  • Randomized Controlled Trials as Topic
  • Renin-Angiotensin System / drug effects
  • Treatment Outcome


  • Adrenergic beta-Antagonists
  • Antihypertensive Agents
  • Calcium Channel Blockers
  • Diuretics