The ESH guidelines and missed prevention opportunities

In their Viewpoint, Franz H Messerli and colleagues state that they are concerned that the 2023 European Society of Hypertension (ESH) guidelines might lead to missed opportunities to prevent stroke events by placing β blockers on equal footing with thiazide diuretics, renin-angiotensin system blockers, and calcium channel blockers. 1 Messerli FH Bangalore S Mandrola JM β blockers switched to first-line therapy in hypertension. Lancet. 2023; (published online Oct 13.)https://doi.org/10.1016/S0140-6736(23)01733-6 Google Scholar We agree that β blockers, mostly atenolol, are less effective than other drug classes at preventing stroke and can have worse side-effect profiles. However, we would go further: any initial blood pressure-lowering monotherapy, whatever the drug class, could be a missed prevention opportunity because of the likelihood that it becomes long-term monotherapy. 2 Cooper-DeHoff RM Fontil V Carton T et al. Tracking blood pressure control performance and process metrics in 25 US health systems: the PCORnet blood pressure control laboratory. J Am Heart Assoc. 2021; 10e022224 Crossref PubMed Scopus (8) Google Scholar This possibility is a real risk since treatment inertia occurs in over 80% of instances of high blood pressure clinic readings, 2 Cooper-DeHoff RM Fontil V Carton T et al. Tracking blood pressure control performance and process metrics in 25 US health systems: the PCORnet blood pressure control laboratory. J Am Heart Assoc. 2021; 10e022224 Crossref PubMed Scopus (8) Google Scholar and all monotherapies are less effective than combination therapy at lowering blood pressure. 3 Wald DS Law M Morris JK Bestwick JP Wald NJ Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med. 2009; 122: 290-300 Summary Full Text Full Text PDF PubMed Scopus (751) Google Scholar Any long-term monotherapy reduces potential benefit, since each extra mm Hg reduction of systolic blood pressure (SBP) lowers cardiovascular disease risk by about 2–3% across all SBP levels above 110 mm Hg. 4 Rahimi K Bidel Z Nazarzadeh M et al. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis. Lancet. 2021; 397: 1625-1636 Summary Full Text Full Text PDF PubMed Scopus (306) Google Scholar β blockers switched to first-line therapy in hypertensionIn their recent guidelines, the European Society of Hypertension upgraded β blockers, putting them on equal footing with thiazide diuretics, renin–angiotensin system blockers (eg, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers), and calcium channel blockers. The reason offered for upgrading β blockers was the observation that they are often used for many other clinical conditions commonly encountered with hypertension. This upgrade would allow for the treatment of two conditions with a single drug (a so-called twofer). Full-Text PDF