Is adding a beta blocker a good choice for patients with elevated diastolic blood pressure (hypertension) despite being on blood pressure (BP) medications?

From the Guidelines

Adding a beta blocker can be considered for patients with elevated diastolic blood pressure despite being on other antihypertensive medications, but only if they are not already indicated and other options like spironolactone have been considered, as recommended by the 2024 ESC guidelines 1. When considering the addition of a beta blocker, it is essential to evaluate the individual's specific situation and existing medication regimen. Beta blockers like metoprolol, atenolol, or carvedilol are particularly useful when the patient has certain coexisting conditions such as coronary artery disease, heart failure, or tachyarrhythmias. Before adding a beta blocker, ensure the patient is already optimized on first-line agents like an ACE inhibitor/ARB and a calcium channel blocker or thiazide diuretic, as these have demonstrated the most effective reduction of BP and CVD events 1. Some key points to consider when adding a beta blocker include:

• They should be used cautiously in patients with asthma, COPD, diabetes, or peripheral vascular disease.
• Common side effects include fatigue, dizziness, and sexual dysfunction.
• Start with a low dose and gradually titrate upward while monitoring blood pressure response.
• If the patient experiences significant side effects or inadequate blood pressure control after adding a beta blocker, consider consulting with a specialist to explore alternative medication strategies. It is also important to note that beta blockers are less effective than ACE inhibitors, ARBs, CCBs, or diuretics at preventing stroke, and have a higher discontinuation rate due to side effects, as highlighted in the 2024 ESC guidelines 1.

From the FDA Drug Label

Many patients will require more than 1 drug to achieve blood pressure goals. Atenolol tablets, USP may be administered with other antihypertensive agents

Adding a beta blocker to other blood pressure medications can be a good choice for patients with elevated diastolic blood pressure despite being on blood pressure medications.

• Key consideration: The decision to add a beta blocker should be based on individual patient needs and medical history.
• Important note: Patients who are dependent on sympathetic stimulation for maintenance of adequate cardiac output and blood pressure may not be good candidates for beta blockade 2. The benefits of beta blockers in reducing cardiovascular morbidity and mortality have been established in various studies, including the ISIS-1 trial 2.

From the Research

Beta Blockers for Elevated Diastolic Blood Pressure

When considering the addition of beta blockers to other blood pressure medications for patients with elevated diastolic blood pressure, several factors come into play. The effectiveness of beta blockers in managing diastolic dysfunction and their role as an add-on therapy are crucial points of discussion.

• Efficacy in Diastolic Dysfunction: Studies such as 3 suggest that while beta blockers can improve indices of diastolic filling, their independent impact on prognosis and outcome in diastolic dysfunction is not fully clarified. This indicates a need for careful consideration when using beta blockers for this specific condition.
• Addition to Other BP Medications: Evidence from 4 and 5 implies that beta blockers may be used in addition to other antihypertensive agents to achieve blood pressure goals, especially in certain patient populations. However, they might not be the first choice for uncomplicated hypertension due to suboptimal stroke reduction compared to other drugs.
• Patient-Specific Considerations: The choice of beta blocker and its suitability can depend on various patient factors, including the presence of other medical conditions like heart failure, angina, diabetes, or asthma. For instance, 6 highlights the importance of selecting the right beta blocker, as some may have diminished efficacy due to intrinsic sympathomimetic activity.

Key Points for Consideration

• Beta blockers can be effective in improving diastolic function but may not be the first-line choice for all patients with hypertension.
• Their use as an add-on therapy should be tailored to the individual patient's condition and response to other medications.
• The specific type of beta blocker used can significantly impact its efficacy and tolerability, with some being more suitable for certain patient groups than others, as discussed in 7.

Decision Making

The decision to add a beta blocker to a patient's regimen for elevated diastolic blood pressure despite being on other BP medications should be based on a comprehensive assessment of the patient's overall health status, the specific characteristics of the beta blocker, and the potential benefits and risks associated with its use, as informed by studies like 6, 3, 4, 5, and 7.