Position of Beta-blockers in the Treatment of Hypertension Today: An Indian Consensus

Background: Management of essential hypertension (HTN) remains challenging, with contemporary control being achieved in <1/10 of the cases, especially when aligned with the recently updated guidelines of American College of Cardiology (ACC) or International Society of Hypertension (ISH). The place and positioning of beta-blockers have been evolving, with recent focused updates, such as the European Society of Hypertension (ESH) 2023 guidelines, that may hold relevance for the Indian phenotypic traits of premature cardiovascular disease (CVD), fragile coronary architecture, and/or high resting heart rate. To further develop consensus on the clinical role and relevance of beta-blockers, including nebivolol, an Indian consensus was evolved with graded recommendations on their clinical role in HTN, HTN with additional cardiovascular (CV) risk, or type 2 diabetes mellitus (T2DM).

Methodology: An expert review panel was constituted, comprising interventional and clinical cardiologists as experts, to synthesize the literature for the development of a validated knowledge, attitude, and practice (KAP) survey questionnaire. Research databases, including Cochrane Systematic Reviews, PubMed, and Google Scholar, were accessed for contemporary information and guidelines on beta-blockers updated until Dec 2023. Delphi rounds were conducted to develop graded recommendations based on the strength, quality of evidence, and the agreement among the panelists (n = 9). Consensus was achieved on the graded recommendations, with ≥70% of national panelists in agreement.

Results: Ninety-six percent of respondents opined that the new ESH HTN guidelines (2023) help gain confidence in using beta-blockers, which are considered first-line drugs for the treatment of HTN. Beta-blockers, including nebivolol, can be recommended in patients with HTN with high resting heart rates, including young hypertensive patients under 40 years of age. For people under 60 years old with HTN, regardless of whether they have comorbid diseases, beta-blockers are the recommended drug choice. Ninety-five percent of respondents opined that nebivolol is the preferred beta-blocker in hypertensive patients with T2DM, followed by bisoprolol and metoprolol. More than 90% of respondents opined that the three most commonly preferred beta-blockers by experts in patients with angina were nebivolol, metoprolol, and bisoprolol.

Conclusion: Beta-blockers, including nebivolol, can be considered initial-line therapy for HTN management in real-life settings in India and nebivolol is preferred because of its two important properties: highest beta-1 selectivity and endothelial-dependent vasodilation.