• Are beta blockers now obsolete?

    It is very rare for new evidence to question or even negate the utility of a well-established class of drugs. But after four decades as a standard therapy for heart disease and high blood pressure, it looks like this fate will befall beta blockers. Two major studies published within about a week of each other suggest that the drugs do not work for these conditions. This is a big surprise, with big implications.

    Read Josh Bloom’s full piece. It’s a fascinating story. The “two major studies” are here and here. Readers who know this area of medicine, what do you think?


    • I remember being told the first week in medical school by Dean Orbison at the University of Rochester that within 10 years half of what we were taught in medical school would no longer be true – but that no one could predict which half.

      I didn’t believe him at the time. I thought it was theatrics to emphasize a point about the necessity of lifelong learning. But he was more right than wrong. That comment was not part of the 50% I have had to relearn every decade.


    • I don’t know if this is helpful, but as a non-expert I looked up the medication (amlidonpine) I was prescribed when I noticed my blood pressure was sneaking up and was rather unimpressed by things like this (0.083 years increased life expectancy):


      Seems a bit of a snore. (The ARB, which was added in when blood pressure started sneaking up again as the weather turned cold this winter, looks a lot more hopeful.)

      Having had a detached retina, I need to keep BP under control, so treatment that doesn’t extend life expectancy still has serious value here. But my _impression_ from reading is that it’s really hard to reduce hypertention (I tried brisk daily one-hour walks and reduced sodium intake: no effect) and small improvements in BP aren’t all that life prolonging. (Brisk 30 minute walks 3 times a week seems about right.)

      So I don’t find it surprising that some older hypertension medication doesn’t actually extend life expectancy.

    • It is not clear that either paper invalidates what was previously thought about beta blockers after AMI. The Bangalore article in JAMA is an observational study of a large database which, as the authors recognize, is susceptible to confounding by indication. The Zuckerman article in the J Am Geriatr Soc is also a study of a large database, but it appears to report lower hazard ratios for the main outcomes with beta blocker therapy.

      Duration of appropriate use has never been clearly defined for beta blockers, but it would be jumping to conclusions to think that observational studies, even of large databases, will overturn conclusions from soundly done randomized trials.

      • I have to echo Ed.

        You must read the commentary of the JAMA paper. The presence of CHF, timing of initiation of BB, concurrent administration of other drugs, and the type of BB, all play a role.

        In HTN, I am not using BB’s as first line therapy (backed by evidence), and I suspect with next release of JNC, they will no longer sit aside ACE, CAB, and diuretics as first line drugs.

        The JAGS paper in isolation does not strike me as a game changer.

        As pointed out, the isolated effects of once useful drugs become less prominent as we utilize more effective polypharm regimens,

        Have you looked in Cochrane database?


    • Would Bloom’s hypothesis that reperfusion makes BB inefficient be in principle testable if there is variation in reperfusion take-up in these databases (over time may be less endogenous)? Creative destruction in treatment innovation is interesting (newer treatments make older ones inefficient).