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Dr. Ghali raises an interesting point about our study (1) that deserves to be scrutinized. In hypertension, beta-blockers as a class have never been shown to reduce heart attacks or strokes (2,3). This is true for atenolol in several prospective placebo-controlled randomized trials, but also for propranolol in the Medical Research Council (MRC) study (4) and for oxprenolol in the International Prospective Primary Prevention Study in Hypertension (IPPPSH) (5). In Cardiac Insufficiency Bisoprolol Study (CIBIS-II), the rate of hospitalization for a stroke was almost twice as high in the bisoprolol arm as in the placebo arm (6). Thus, there are several prospective randomized studies with atenolol, propranolol, oxprenolol, or bisoprolol documenting that beta-blockers are not efficacious in reducing strokes.
A notable exception that Dr. Ghali mentioned is the Carvedilol Or Metoprolol European Trial (COMET) in congestive heart failure patients (7). However, carvedilol is a drug that is distinctly different from traditional beta-blockers in that it does have some alpha-blocking properties and other features that exert a more favorable effect on systemic hemodynamic, metabolic endocrine findings, and target organ disease than do traditional beta-blockers (8). We also should emphasize that a stroke reduction in congestive heart failure without hypertension cannot necessarily be extrapolated to uncomplicated hypertension. Indeed, heart failure per se is a risk factor for stroke, but the pathogenesis is different from the one in hypertension and often involves emboli of cardiac origin. Because carvedilol was superior to metoprolol in preventing congestive heart failure and sudden death, it is likely that it decreased stroke risk, at least to some extent, by cardiac protection. Thus, there is little doubt that, for stroke prevention in essential hypertension, beta-blockers (with the possible exception of carvedilol) are not the drugs of choice.
- American College of Cardiology Foundation
- Fournier A.,
- Messerli F.H.,
- Achard J.M.,
- Fernandez L.
- Messerli F.H.,
- Beevers D.G.,
- Franklin S.S.,
- Pickering T.G.
- Medical Research Council Working Party
- ↵Reduced costs with bisoprolol treatment for heart failure: an economic analysis of the second Cardiac Insufficiency Bisoprolol Study (CIBIS-II). Eur Heart J 2001;22:1021–31.