Expert Panel Reaffirms Beta-blockers as First-Line Therapy for Hypertension in India

Hypertension, a condition affecting millions worldwide, remains a significant health challenge, especially in India, where early cardiovascular disease (CVD) is a growing concern. Despite advances in treatment, the management of essential hypertension continues to be difficult, with control achieved in fewer than 1 in 10 cases, particularly when aligned with updated guidelines from the American College of Cardiology (ACC) and the International Society of Hypertension (ISH). In response to these challenges, the positioning of beta-blockers, particularly nebivolol, has evolved, with a focus on their relevance to the Indian population's unique characteristics, including premature CVD, fragile coronary architecture, and high resting heart rates.

The panel, comprising clinical and interventional cardiologists, synthesized current evidence to provide graded recommendations based on guidelines, including the 2023 updates of the European Society of Hypertension (ESH). The Indian consensus aims to clarify the clinical role of beta-blockers in treating hypertension, particularly when compounded by comorbid conditions such as T2DM and cardiovascular risk factors.

The consensus findings emphasize the pivotal role of beta-blockers, including nebivolol, in hypertension management. An overwhelming 94% of the panelists agreed that the 2023 ESH hypertension guidelines have increased confidence in the use of beta-blockers as a first-line therapy for HTN. In particular, beta-blockers are recommended for individuals with hypertension who exhibit high resting heart rates, such as younger hypertensive patients under the age of 40. Moreover, for those under 60 years old, regardless of comorbid conditions, beta-blockers are considered the preferred drug choice.

For hypertensive patients with T2DM, 95% of the experts favored nebivolol due to its beneficial effects in managing both hypertension and diabetes. Nebivolol was also deemed the most suitable beta-blocker for patients with angina, with metoprolol and bisoprolol following closely behind in preference. In patients with chronic obstructive pulmonary disease (COPD) and hypertension, nebivolol was once again the most preferred option, as it tends to cause fewer pulmonary side effects compared to other beta-blockers.

The study also highlighted the importance of combining nebivolol with angiotensin receptor blockers (ARBs) in patients who do not respond well to ARB monotherapy. This combination therapy was shown to be particularly effective for hypertensive patients with diabetes and those suffering from ischemic heart disease (IHD), such as those presenting with angina or myocardial infarction (MI).

Consensus on the Role of Beta-blockers in Hypertension Treatment

1. First-line Treatment
   Beta-blockers are classified as first-line drugs for the treatment of hypertension (HTN).
• 94% of respondents stated that the updated ESH HTN guidelines (2023) have increased confidence in using beta-blockers for HTN management.
2. Beta-blockers in Comorbid Conditions
   Beta-blockers are recommended in the treatment of HTN, particularly for patients with comorbid conditions such as myocardial infarction (MI), heart failure with reduced ejection fraction (HFrEF), and atrial fibrillation (AF).
• They are also beneficial in patients with high resting heart rates, providing additional protection.
3. High Resting Heart Rates
   Beta-blockers should be prescribed to patients with HTN who have high resting heart rates, including younger hypertensives under the age of 40.
4. Resting Heart Rate and Blood Pressure
   In the general population, resting heart rate is a significant predictor of blood pressure and mortality risk.
• Beta-blockers are recommended for patients under 60 years of age with HTN, regardless of the presence of comorbid diseases.
5. Nebivolol in Hypertensive Patients with Diabetes
   Nebivolol is the most preferred beta-blocker for hypertensive patients with diabetes.
• Other commonly preferred options include bisoprolol and metoprolol.
6. Beta-blockers in COPD and HTN
   Nebivolol is the preferred beta-blocker for patients with both chronic obstructive pulmonary disease (COPD) and HTN due to its favorable side effect profile.
7. Nebivolol + ARB Combination
   The combination of nebivolol and angiotensin receptor blockers (ARBs) can be considered in:
• Patients who do not respond well to ARB monotherapy
• Hypertensive patients with diabetes
• Patients with HTN and ischemic heart disease (IHD), particularly those experiencing angina or myocardial infarction (MI).

"The consensus firmly places beta-blockers, especially nebivolol, at the forefront of hypertension treatment in India. The findings support their use in various patient subsets, including those with high resting heart rates, younger hypertensives, and patients with comorbid conditions like T2DM and COPD. Given the unique health challenges in India, these updated recommendations provide a comprehensive approach to managing hypertension, ensuring better long-term outcomes for patients," the researchers concluded.

Reference:

Mohan JC, Roy DG, Ray S, et al. Position of Beta-blockers in the Treatment of Hypertension Today: An Indian Consensus. J Assoc Physicians India 2024;72(10):83-90.