Beta-Blockers Still Frequently Prescribed First-Line for Hypertension at VA

Practice Is Discordant with Most Guidelines

SALT LAKE CITY — For more than a decade, national guidelines have discouraged first-line beta-blocker use among patients without compelling indications. Yet, according to a new study, the practice is still common at the VHA, and interventions are needed to improve guideline-concordant initial treatment for hypertension.

Writing in JAMA Network Open, researchers from the University of Utah and the George E. Wahlen VAMC, both in Salt Lake City, sought to determine the prevalence and the factors associated with first-line beta-blocker use for hypertension among those without compelling indications that type of blood-pressure lowering medication. ¹

To do that, they conducted a cross-sectional study of 774,821 veterans initiating a beta-blocker for hypertension between 2000 and 2022. The study team noted that the proportion without a compelling indication was high (88% overall) but decreased over time (92% to 82%).

“Among those without compelling indications, beta-blocker initiation varied by sociodemographic and clinical factors, including age, sex, race and ethnicity, and history of comorbid conditions,” the study team advised, adding, “These findings suggest that despite national guidelines discouraging first-line beta-blocker use among those without compelling indications since 2014, this practice is still common, and interventions are needed to improve guideline-concordant initial treatment for hypertension.”

Because of their tolerability profile and inferior protection against stroke and mortality compared with other first-line agents, beta-blockers stopped being recommended for routine first-line hypertension treatment in 2014

The serial cross-sectional study zeroed in on new antihypertensive prescriptions using national, patient-level data in the VHA between Jan. 1, 2000, and Dec. 31, 2022. Included were veterans initiating antihypertensive medications for newly diagnosed hypertension in the outpatient setting based on diagnosis codes and prescription dispenses, excluding veterans without a primary care visit in the prior year. The participants did not have competing indications, such as aortic aneurysm and/or disease, angina, atrial fibrillation or arrhythmia, chronic liver disease or cirrhosis, heart failure with reduced ejection fraction, myocardial infarction, or coronary revascularization, which would have justified the beta-blocker initiation.

The about 3.1 million veterans included had a mean age of 61 and 94.3% were male. Most 64.6% were non-Hispanic white, with 15.6% non-Hispanic Black, 4.8% Hispanic and 2.1% other races and ethnicities.

Of those, 24.7% initiated a beta-blocker, and 88.2% of veterans in that group did not have compelling indications, which decreased over time from 245,703 (91.8%) in 2000 through 2005 to 93,088 (81.5%) in 2018 to 2022.

“Metoprolol and carvedilol were the most commonly initiated beta-blockers and increased over time, and atenolol initiation decreased over time,” the researchers wrote. “ Among other factors, a greater prevalence ratio for beta-blocker initiation was observed among older (PR, 1.05; 95% CI, 1.04-1.05), female (PR, 1.11; 95% CI, 1.09-1.14), non-Hispanic white (as reference group; Non-Hispanic Black PR, 0.74; 95% CI, 0.73-0.76; Hispanic PR, 0.75; 95% CI, 0.73-0.77; all others PR, 0.89; 95% CI, 0.86-0.92) or frail veterans (PR, 1.28; 95% CI, 1.25-1.31).”

Background information in the articles pointed out that guideline recommendations regarding beta-blocker use for first-line treatment of high blood pressure (BP) “have changed significantly over the past 3 decades. In the 1980s and 1990s, several placebo-controlled trials demonstrated their efficacy to prevent adverse cardiovascular disease (CVD) events, leading to first-line endorsement alongside thiazide and thiazide-like diuretics (hereafter, thiazides) in the Sixth and Seventh Reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC6 and JNC7, respectively). This changed in 2014 with the Eighth JNC Report (JNC8) recommending beta-blockers as first-line only for patients with ‘compelling indications’ supported by strong evidence of benefit.”

At that point, they wrote, beta–blockers were relegated to second-line therapy after angiotensin-converting enzyme inhibitors, angiotensin-2 receptor blockers (ARB), thiazides, and calcium channel blockers (CCB).

“This shift was based on trials and meta-analyses suggesting inferior stroke and mortality as well as higher discontinuation rates from adverse effects,” according to the authors. “Similar recommendations appeared in the 2017 American College of Cardiology/American Heart Association (ACC/AHA) BP guidelines and were reinforced in the 2024 AHA/American Stroke Association Guideline for the Primary Prevention of Stroke. In contrast, the 2018 and 2023 updates of the European Society of Hypertension (ESH) guidelines supported first-line beta-blocker use for uncomplicated hypertension, citing their efficacy compared with placebo in lowering BP and preventing CVD.”

The investigators advised that the quality of hypertension care for U.S. veterans has been a major focus of the VHA, which is the largest integrated healthcare system in the U.S. The VA/DoD Hypertension Clinical Practice Guidelines in 2004, 2014 and 2020 conformed with the recommendations outlined in the JNC7, JNC8 and 2017 ACC/AHA guidelines.

“However, in our recent analyses,” the study team wrote, “we identified that beta-blockers are prescribed as first-line hypertension treatment in approximately 20% of veterans who do not have a compelling indication, although this trend decreased over the 20-year study. To improve evidence-based prescribing of beta-blockers for treatment of high BP, we sought to investigate the clinical factors associated with beta-blocker use in a cohort of veterans initiating treatment for high BP over 23 years.”

The authors suggested that their serial cross-sectional study of over 3 million veterans initiating treatment for incident hypertension has 3 main takeaways.

“First, 88.3% of patients initiating beta-blockers did not have a compelling indication, and although this proportion decreased over time, it is nonetheless high at 81.5% in the most recent years of the study,” they explained. “Second, initiation of atenolol has decreased in favor of initiating metoprolol or carvedilol, with significant increases in propranolol use among those without compelling indications.

“Finally, in adjusted models, factors that were associated with increased likelihood of beta-blocker initiation in the absence of compelling indications included older age, female, race and ethnicity, current smoking status, presence of frailty, individuals who were hospitalized in the year before the index date, and receiving care in urban settings or the Northeast US region. Taken together, these findings identify target populations for improving the initial prescribing of antihypertensive regimens to optimize cardiovascular outcomes among U.S. veterans.”

The researchers went on to explain, “Compared with first-line agents, beta=blockers represent the most pharmacodynamically heterogenous antihypertensive medication class. Individual beta-blockers vary by beta-1 receptor selectivity, intrinsic sympathomimetic activity, and peripheral vasodilation via alpha-1 blockade or nitric oxide release.”

They noted that atenolol, a beta-1 selective antagonist without intrinsic sympathomimetic activity or vasodilation properties, was the beta-blocker used in many early trials comparing beta-blockers with placebo or other antihypertensives.

”These pivotal trials determined that beta-blockers were superior to placebo to prevent CVD but inferior to thiazides, CCBs, or ARBs to prevent CVD, specifically stroke and all-cause mortality,” the study explained. “These data, supported by subsequent meta-analyses, formed the basis for not recommending beta-blockers as a first-line class due to both adverse effects (eg, fatigue and bradyarrhythmias) and inferior CVD clinical outcomes.7”

Yet, they pointed out, “Some argue that atenolol’s shorter duration of action and once-daily dosing in these studies contributed to suboptimal BP-lowering, consequently leading to inferior stroke protection, although comparative data with other beta-blockers are inconclusive. Nevertheless, the lack of efficacy was generalized to the class, despite the potential that beta-blocker efficacy for essential hypertension may not be a class effect—similar to their use in heart failure with reduced ejection fraction, where only metoprolol succinate, bisoprolol, and carvedilol have demonstrated outcome benefits.”

They said their current analysis observed prescribing differences according to

• age,
• history of alcohol-use disorder,
• chronic kidney disease or end-stage kidney disease and/or dialysis,
• depression,
• diabetes,
• frailty, and
• obstructive sleep apnea.

“These findings underscore the need to prioritize guideline-recommended first-line agents and to critically evaluate beta-blocker prescribing in the absence of clear clinical indications, which may expose patients to avoidable harm without comparable benefit,” the authors argued. “Over the 23-year study period, we found marked reductions in atenolol initiation alongside increases in metoprolol, carvedilol, and propranolol. As recommended by the 2023 ESH BP guidelines and others, additional studies are needed to compare newer beta-blockers with one another and atenolol for uncomplicated hypertension.”

 

1. Derington CG, Berchie RO, Mohanty AF, et al. First-Line beta-Blocker Use for Hypertension in the Veterans Health Administration. JAMA Netw Open. 2025;8(8):e2529026. doi:10.1001/jamanetworkopen.2025.29026.