117/78 at the moment, but I’ve been on empa for months. Was 111/71 yesterday when I checked. Planning to stop the tiny dose of nebivolol 2.5 mg and go from 40mg to 80mg telmisartan by the end of the week. Not going to bother with adding a true diuretic unless BP doesn’t remain well controlled.
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Another position paper against the return of beta-blockers in the recent European guidelines: For Debate: The 2023 European Society of Hypertension guidelines - cause for concern 2024
Originally, the beta-blockers were equally ranked alongside the other antihypertensive drug classes. Things changed when two major long-term randomized controlled trials, ASCOT-BPLA and LIFE showed that the patients receiving the beta-blockers based regimes suffered 25–30% more strokes than those receiving a calcium channel blocker based regime or an angiotensin receptor blocker based regime. The inferiority of the beta-blockers at stroke prevention was not due to differences in blood pressure control during the follow-up period in both trials. The 2023 European Society of Hypertension (ESH) guidelines still argue in favour of beta-blockers that their clinical inferiority was simply to lesser blood pressure reduction rather than class effect. The analysis argues that the return of beta-blockers as a first-line option for the management of uncomplicated hypertension by the ESH is a cause for concern and should be reconsidered.
Given this evidence, it seems strange that the new 2023 ESH guidelines reinstate the beta-blockers as suitable first-line therapy for hypertension, although with caveats in other paragraphs. Why is this volte-face based on no new evidence? The message is confusing, and we profoundly disagree. We are not alone in these views; Messerli, Bangalore and Mandrola share many of our sentiments in a similarly detailed review.
Sadly, all the guideline committees (from the USA, the UK and Europe) largely comprise hospital-based specialists. In contrast, most patients with hypertension are managed exclusively in primary care settings because they are less likely to have cardiovascular complications of hypertension. Hospital-based hypertension specialists are more likely to encounter more complex cases many of whom may have suffered the vascular complications of hypertension. The re-endorsement of the beta-blockers for uncomplicated hypertension might not have happened if more primary care physicians had had greater input into the preparation of the guidelines.
To some extent, arguments about first-line drugs are of only limited use as, in most patients, double or triple therapy is necessary to bring the BP under control. But even then, the beta-blockers are only required if there is concomitant heart disease. In primary healthcare, such patients are in the minority. Hence, the return of beta-blockers as a first-line option for the management of uncomplicated hypertension by the ESH is a cause for concern and should be reconsidered.
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Beta blockers are good for aortic stenosis. I have moderate regurgitation/stenosis so I am going to remain on 5mg nebivolol I think, even though I don’t have high BP without it.
Arterial Hypertension in Aortic Valve Stenosis: A Critical Update - PMC (nih.gov)
" If blood pressure is not yet controlled by RAAS blocking, the addition of a beta-blocker (BB) should be considered; among these, metoprolol has the greatest literature evidence, showing not only an improvement in hemodynamic and metabolic performance but also a reduction in mortality in patients who already presented with coronary artery disease [77,78].
BB therapy was also linked to decreased rates of cardiac and all-cause mortality, along with sudden cardiac death, and was not linked to an increased incidence of heart failure prior to AVR [79]."
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I have been taking metoprolol prescribed by a locally imminent cardiologist for more than a decade. I recently (several months ago) added telmisartan (self-prescribed).
People may wonder why I do these things. It is because I am on a quest to optimize what is presently known to be optimal in the form of things I can measure.
I like Peter Attia’s approach to optimization, but I could not possibly adhere to his diet.
So I am trying to optimize, as others in the forum are doing, by adjusting my supplements, medications, and a diet that I can adhere to optimize my blood markers and blood pressure. My advice to naysayers is; just don’t do it. I am not advising anything, just reporting what I do and my own observations.
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Yes beta blockers might be good for some specific indications, for instance, arrhythmias. However, for essential hypertension and for neuroprotection, they’re not recommended as of today.