What is the recommended approach for using atenolol (beta-blocker) and losartan (angiotensin II receptor antagonist) together in the management of hypertension?

Combining Atenolol and Losartan in Hypertension Management

The combination of atenolol (beta-blocker) and losartan (angiotensin II receptor antagonist) is not recommended as a preferred combination for hypertension management due to suboptimal outcomes compared to other combinations. 1

Evidence-Based Rationale

Efficacy Considerations

• Losartan has demonstrated superior cardiovascular protection compared to atenolol in patients with hypertension and left ventricular hypertrophy, reducing the risk of cardiovascular events by 24% and all-cause mortality by 39%, despite similar blood pressure reductions 2
• The LIFE study showed that losartan was more effective than atenolol in preventing cardiovascular morbidity and death, predominantly stroke, independent of blood pressure reduction 3
• Several studies have consistently demonstrated greater regression of left ventricular hypertrophy with losartan than with atenolol 1

Preferred Combination Strategies

• Current guidelines recommend combining a RAS blocker (ACE inhibitor or ARB like losartan) with either:
  • A dihydropyridine calcium channel blocker
  • A thiazide/thiazide-like diuretic 1
• These combinations have shown better outcomes in reducing cardiovascular events compared to beta-blocker combinations 1

Metabolic Considerations

• The combination of a beta-blocker (like atenolol) and a thiazide diuretic has been associated with dysmetabolic effects 1
• Losartan has been shown to reduce new-onset diabetes compared to atenolol (relative risk 0.69) 3

Algorithm for Hypertension Management

1. First-line approach:

   • For most patients with confirmed hypertension (≥140/90 mmHg), initiate with a combination of:
     • RAS blocker (losartan) + dihydropyridine CCB or
     • RAS blocker (losartan) + thiazide/thiazide-like diuretic 1

2. When to consider beta-blockers:

   • Beta-blockers like atenolol should be reserved for patients with specific compelling indications:
     • Angina
     • Post-myocardial infarction
     • Heart failure with reduced ejection fraction
     • Heart rate control 1

3. If target BP not achieved:

   • Progress to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
   • Consider using fixed-dose single-pill combinations to improve adherence 1

Special Considerations

• Left ventricular hypertrophy: Losartan is superior to atenolol for regression of LVH and reduction of cardiovascular events 1, 2
• Diabetes risk: Losartan is associated with lower risk of new-onset diabetes compared to atenolol 3
• Blood pressure targets: Current guidelines recommend targeting systolic BP of 120-129 mmHg for most adults, if well tolerated 1
• Contraindications: Combining two RAS blockers (such as ACE inhibitor and ARB) is not recommended 1

Conclusion for Clinical Practice

For hypertension management, the evidence strongly favors using losartan in combination with either a calcium channel blocker or a thiazide diuretic rather than combining it with atenolol. If a patient has a specific indication for beta-blocker therapy (such as coronary artery disease), consider using the beta-blocker as part of a different regimen, but the atenolol-losartan combination specifically lacks evidence of superior outcomes and is not among the preferred combinations in current guidelines.