What is the best course of action for a patient with uncontrolled hypertension on atenolol (beta blocker) 25mg?

Management of Uncontrolled Hypertension on Atenolol 25mg

For a patient with uncontrolled hypertension on atenolol 25mg, you should discontinue the beta-blocker and initiate combination therapy with an ACE inhibitor or ARB plus a calcium channel blocker, as beta-blockers are not recommended as first-line agents for hypertension. 1

Why Beta-Blockers Are Not Appropriate First-Line Therapy

• Beta-blockers are explicitly not recommended as first-line agents for hypertension unless the patient has ischemic heart disease or heart failure. 1
• The 2017 ACC/AHA guidelines clearly state that atenolol and other beta-blockers should be reserved for patients with compelling indications (IHD, HF, or specific arrhythmias), not for routine hypertension management. 1
• The 2024 ESC guidelines similarly emphasize that the four major drug classes (ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics) are the recommended first-line medications. 1

Recommended Treatment Algorithm

Step 1: Initiate Combination Therapy

• Start with a low-dose combination of an ACE inhibitor (or ARB) plus a calcium channel blocker as initial therapy. 1
• Single-pill combinations are preferred for better adherence. 1
• The 2024 ESC guidelines provide a Class I recommendation for upfront combination therapy in confirmed hypertension. 1

Step 2: If Blood Pressure Remains Uncontrolled After 1-3 Months

• Escalate to low-dose triple combination therapy: ACE inhibitor/ARB + CCB + thiazide-like diuretic. 1
• Ensure drugs are at optimal or maximally tolerated doses before adding additional agents. 1

Step 3: If Still Uncontrolled on Triple Therapy

• Add spironolactone 25mg once daily (if serum potassium <4.6 mmol/L). 1
• If spironolactone is not tolerated, consider eplerenone (50-100mg, may require twice daily dosing), or a beta-blocker if not already indicated. 1
• At this stage, refer to an expert center for resistant hypertension workup and assess medication adherence. 1

Important Caveats About Atenolol

Dosing Considerations

• If you must continue atenolol for a compelling indication, the current 25mg dose is subtherapeutic. 2
• The usual dose range for atenolol in hypertension is 25-100mg daily, with maximum effect typically seen at 100mg. 1, 2
• Atenolol can be given once daily due to its prolonged half-life. 2, 3

Specific Precautions

• Avoid abrupt cessation of atenolol, which can precipitate rebound hypertension or angina. 1
• Atenolol is renally excreted; dose adjustment is required in renal impairment (25mg daily if creatinine clearance <15 mL/min). 2
• Do not combine beta-blockers with nondihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block. 1

When Beta-Blockers May Be Appropriate

• Beta-blockers should only be considered in younger patients with contraindications to ACE inhibitors/ARBs, women of childbearing potential, or patients with evidence of increased sympathetic drive. 1
• If a beta-blocker is started and a second drug is required, add a CCB rather than a thiazide-like diuretic to reduce diabetes risk. 1

Monitoring Target

• Aim to reduce blood pressure by at least 20/10 mmHg, ideally to <130/80 mmHg, within 3 months. 1
• Reassess at 1 month if possible to ensure adequate response. 1