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Review
. 2016 Mar 10;3(3):CD007451.
doi: 10.1002/14651858.CD007451.pub2.

Blood pressure lowering efficacy of beta-1 selective beta blockers for primary hypertension

Gavin W K Wong  1 , Heidi N Boyda, James M Wright
Affiliations
Review

Blood pressure lowering efficacy of beta-1 selective beta blockers for primary hypertension

Gavin W K Wong et al. Cochrane Database Syst Rev. .

Abstract

Background: Beta blockers are commonly used to treat hypertension. The blood pressure reading is the primary tool for physicians and patients to assess the efficacy of the treatment. The blood pressure lowering effect of beta-1 selective blockers is not known.

Objectives: To quantify the dose-related effects of various doses and types of beta-1 selective adrenergic receptor blockers on systolic and diastolic blood pressure versus placebo in people with primary hypertension.

Search methods: We searched the Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.We searched the following databases for primary studies: the Cochrane Hypertension Specialised Register (All years to 15 October 2015), CENTRAL via the Cochrane Register of Studies Online (2015, Issue 10), Ovid MEDLINE (1946 to 15 October 2015), Ovid EMBASE (1974 to 15 October 2015) and ClinicalTrials.gov (all years to 15 October 2015).The Hypertension Group Specialised Register includes controlled trials from searches of CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, Food Science and Technology Abstracts (FSTA), Global Health, LILACS, MEDLINE, ProQuest Dissertations & Theses, PsycINFO, Web of Science and the WHO International Clinical Trials Registry Platform (ICTRP).Electronic databases were searched using a strategy combining the Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity-maximizing version (2008 revision) with selected MeSH terms and free text terms. No language restrictions were used. The MEDLINE search strategy was translated into CENTRAL, EMBASE, the Hypertension Group Specialised Register and ClinicalTrials.gov using the appropriate controlled vocabulary as applicable. Full strategies are in Appendix 1.

Selection criteria: Randomised, double-blind, placebo-controlled parallel or cross-over trials. Studies had to contain a beta blocker monotherapy arm with fixed dose. People enrolled into the studies had to have primary hypertension at baseline. Duration of studies had to be between 3 weeks to 12 weeks. Drugs in this class of beta blockers are atenolol, betaxolol, bevantolol, bisoprolol, esmolol, metoprolol, nebivolol, pafenolol, practolol.

Data collection and analysis: Two authors confirmed the inclusion of studies and extracted the data independently. Review Manager (RevMan) 5.3.5 was used to synthesise data.

Main results: We identified 56 RCTs (randomised controlled trials) that examined the blood pressure (BP) lowering efficacy of beta-1 selective blockers (beta-1 blocker) in 7812 primary hypertensive patients. Among the included trials, 26 RCTs were parallel studies and 30 RCTs were cross-over studies, examining eight beta-1 blockers. Overall, the majority of beta-1 blockers studied significantly lowered systolic blood pressure (SBP) and diastolic blood pressure (DBP). In people with mild to moderate hypertension, beta-1 selective blockers lowered BP by an average of -10/-8 mmHg and reduced heart rate by 11 beats per minute. The maximum BP reduction of beta-1 blockers occurred at twice the starting dose. Individual beta-1 blockers did not exhibit a graded dose-response effect on SBP and DBP over the recommended dose range.Most beta-1 blockers tested significantly lowered heart rate. A graded dose-response of beta-1 blockers on heart rate was evident. Higher dose beta-1 blockers lowered heart rate more than lower doses. Individually and overall beta-1 blockers did not affect pulse pressure, which distinguishes them from other classes of drugs.

Authors' conclusions: This review provides low quality evidence that in people with mild to moderate hypertension, beta-1 selective blockers lowered BP by an average of -10/-8 mmHg and reduced heart rate by 11 beats per minute as compared to placebo. The effect of beta-1 blockers at peak hours, -12/-9 mmHg, was greater than the reduction at trough hours, -8/-7 mmHg. Beta-1 selective blockers lowered BP by a greater magnitude than dual receptor beta-blockers and partial agonist beta-blockers, lowered BP similarly to nonselective beta-blockers. Beta-1 selective blockers lowered SBP by a similar degree and lowered DBP by a greater degree than diuretics, angiotensin converting enzyme inhibitors and angiotensin receptor blockers. Because DBP is lowered by a similar extent to SBP, beta-1 selective blockers do not reduce pulse pressure.

PubMed Disclaimer

Conflict of interest statement

Gavin Wong: nothing to declare Heide Boyda: nothing to declare James Wright: nothing to declare.

Figures

1
1
PRISMA study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of nebivolol 5 mg to 20 mg (SBP)
4
4
Funnel plot of nebivolol 5 mg to 20 mg (DBP)
1.1
1.1. Analysis
Comparison 1 Nebivolol vs Placebo, Outcome 1 SBP.
1.2
1.2. Analysis
Comparison 1 Nebivolol vs Placebo, Outcome 2 DBP.
1.3
1.3. Analysis
Comparison 1 Nebivolol vs Placebo, Outcome 3 Heart rate.
1.4
1.4. Analysis
Comparison 1 Nebivolol vs Placebo, Outcome 4 Pulse Pressure.
1.5
1.5. Analysis
Comparison 1 Nebivolol vs Placebo, Outcome 5 Peak vs Trough SBP.
1.6
1.6. Analysis
Comparison 1 Nebivolol vs Placebo, Outcome 6 Peak vs Trough DBP.
2.1
2.1. Analysis
Comparison 2 Atenolol vs Placebo, Outcome 1 SBP.
2.2
2.2. Analysis
Comparison 2 Atenolol vs Placebo, Outcome 2 DBP.
2.3
2.3. Analysis
Comparison 2 Atenolol vs Placebo, Outcome 3 Heart rate.
2.4
2.4. Analysis
Comparison 2 Atenolol vs Placebo, Outcome 4 Pulse pressure.
3.1
3.1. Analysis
Comparison 3 Metoprolol vs Placebo, Outcome 1 SBP.
3.2
3.2. Analysis
Comparison 3 Metoprolol vs Placebo, Outcome 2 DBP.
3.3
3.3. Analysis
Comparison 3 Metoprolol vs Placebo, Outcome 3 Heart rate.
3.4
3.4. Analysis
Comparison 3 Metoprolol vs Placebo, Outcome 4 Pulse pressure.
4.1
4.1. Analysis
Comparison 4 Bisoprolol vs placebo, Outcome 1 SBP.
4.2
4.2. Analysis
Comparison 4 Bisoprolol vs placebo, Outcome 2 DBP.
4.3
4.3. Analysis
Comparison 4 Bisoprolol vs placebo, Outcome 3 Heart rate.
4.4
4.4. Analysis
Comparison 4 Bisoprolol vs placebo, Outcome 4 Pulse pressure.
5.1
5.1. Analysis
Comparison 5 Betaxolol vs Placebo, Outcome 1 SBP.
5.2
5.2. Analysis
Comparison 5 Betaxolol vs Placebo, Outcome 2 DBP.
5.3
5.3. Analysis
Comparison 5 Betaxolol vs Placebo, Outcome 3 Heart rate.
5.4
5.4. Analysis
Comparison 5 Betaxolol vs Placebo, Outcome 4 Pulse pressure.
6.1
6.1. Analysis
Comparison 6 Bevantolol vs Placebo, Outcome 1 SBP.
6.2
6.2. Analysis
Comparison 6 Bevantolol vs Placebo, Outcome 2 DBP.
6.3
6.3. Analysis
Comparison 6 Bevantolol vs Placebo, Outcome 3 Heart rate.
6.4
6.4. Analysis
Comparison 6 Bevantolol vs Placebo, Outcome 4 Pulse pressure.
7.1
7.1. Analysis
Comparison 7 Pafenolol vs Placebo, Outcome 1 SBP.
7.2
7.2. Analysis
Comparison 7 Pafenolol vs Placebo, Outcome 2 DBP.
7.3
7.3. Analysis
Comparison 7 Pafenolol vs Placebo, Outcome 3 Heart rate.
7.4
7.4. Analysis
Comparison 7 Pafenolol vs Placebo, Outcome 4 Pulse pressure.
8.1
8.1. Analysis
Comparison 8 Practolol vs Placebo, Outcome 1 SBP.
8.2
8.2. Analysis
Comparison 8 Practolol vs Placebo, Outcome 2 DBP.
8.3
8.3. Analysis
Comparison 8 Practolol vs Placebo, Outcome 3 Heart rate.
8.4
8.4. Analysis
Comparison 8 Practolol vs Placebo, Outcome 4 Pulse pressure.
9.1
9.1. Analysis
Comparison 9 Pooled overall effect, Outcome 1 SBP.
9.2
9.2. Analysis
Comparison 9 Pooled overall effect, Outcome 2 DBP.
9.3
9.3. Analysis
Comparison 9 Pooled overall effect, Outcome 3 Heart rate.
9.4
9.4. Analysis
Comparison 9 Pooled overall effect, Outcome 4 Pulse pressure.
9.5
9.5. Analysis
Comparison 9 Pooled overall effect, Outcome 5 WDAE.
9.6
9.6. Analysis
Comparison 9 Pooled overall effect, Outcome 6 SBP combined starting dose and 2 x starting dose.
9.7
9.7. Analysis
Comparison 9 Pooled overall effect, Outcome 7 DBP combined starting dose and 2 x starting dose.
9.8
9.8. Analysis
Comparison 9 Pooled overall effect, Outcome 8 Heart rate combined starting dose and 2 x starting dose.
9.9
9.9. Analysis
Comparison 9 Pooled overall effect, Outcome 9 Pulse pressure combined starting dose and 2 x starting dose.
9.10
9.10. Analysis
Comparison 9 Pooled overall effect, Outcome 10 SBP test for 2 x starting dose subgroup difference.
9.11
9.11. Analysis
Comparison 9 Pooled overall effect, Outcome 11 DBP test for 2 x starting dose subgroup difference.
9.12
9.12. Analysis
Comparison 9 Pooled overall effect, Outcome 12 Heart rate test for 2 x starting dose subgroup difference.
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