Hypertension: in elderly patients, beta-blockers are less effective as first-line therapy than diuretics.

Clinical bottom line (level 1a)

  1. Elderly hypertensive patients who are given diuretics (NNT = 43 at 5 years) or beta-blockers (NNT = 61 at 5 years) as first-line therapy are less likely to have cerebrovascular events, than those given a control.
  2. Diuretics (NNT = 51 at 5 years) , but not beta-blockers make coronary heart disease less likely at 5 years.
  3. Diuretics (NNT = 59 at 5 years) , but not beta-blockers make death less likely at 5 years.
Messerli et al: Journal of the American Medical Association 1998; 279 (23): 1903-1907
Expires March 2003

The study

Systematic review of randomised trials of
  • Patients: elderly (aged 60 or more) hypertensive patients
  • Intervention: diuretics and/or beta-blockers as first-line agents compared with placebo or control
  • Outcome: morbidity and mortality


    • Articles found in English using MEDLINE, CARDLINE, 1966 to 1998 (search terms: hypertension (drug therapy) and elderly or geriatric or aged, and cerebrovascular or cardiovascular diseases, and morbidity or mortality ) and pertinent articles cited as references in identified trials and reviews were also searched

    Selection criteria: as above
    Appraisal criteria: not detailed
    Articles excluded if: trials lasted less than one year, beta-blocker and diuretic actions not reported separately, post-stroke patients only

    Ten trials involving 16 164 patients were included (8217 received active treatment; 7 trials used a diuretic as the first drug of choice)
    No heterogeneity was noted.
  • Trials which involved younger patients as well as older patients were included if the patients were stratified for age 60 years and older.
  • Patients were followed for an average of about five years.

    • The evidence

    Outcome Time to outcome CER OR
    (95% CI)    		 NNT
    (95% CI)
    diuretics- cerebrovascular events 5 years 412/6661
    (6.19%)    		 0.61
    (0.51 to 0.72)     		43
    (34 to 60)
    beta-blockers- cerebrovascular disease 5 years 178/2678
    (6.65%)    		 0.74
    (0.57 to 0.98)     		61
    (36 to 800)
    diuretics- coronary heart disease 5 years 531/6661
    (7.97%)    		 0.74
    (0.64 to 0.86)     		51
    (37 to 96)
    beta-blockers- coronary heart disease 5 years 197/2678
    (7.36%)    		 1.01
    (0.80 to 1.29)     		-1500
    (NNT = 72 to infinity;
    NNH = 52 to infinity)
    diuretics- all-cause mortality 5 years 907/6618
    (13.7%)    		 0.86
    (0.77 to 0.96)     		59
    (36 to 210)
    beta-blockers- all-cause mortality 5 years 384/2678
    (14.3%)    		 1.05
    (0.88 to 1.25)     		-160
    (NNT = 67 to infinity;
    NNH = 34 to infinity)

    Citation

    1. Messerli FH, Grossman F, Goldbourt U: Are beta-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. Journal of the American Medical Association 1998; 279 (23): 1903-1907
    Contributor: Clare Wotton and Bob Phillips, July 2000
    Reviewer:

    Clinical Question.
    Patient elderly patients with hypertension
    Intervention or Exposure beta-blockers
    Outcome morbidity and mortality