Carlberg B et al. (2004) Atenolol in hypertension: is it a wise choice? Lancet 364: 1684–1689

A new systematic review by Carlberg and colleagues has revealed that atenolol, one of the most common β-blockers, might not be appropriate as a first-line treatment for hypertension.

In a meta-analysis of four randomized, controlled trials comparing the drug with placebo (or no treatment) in 6,825 patients, there were no overall differences in the risk of all-cause mortality, cardiovascular mortality or myocardial infarction during a mean follow-up of 4.6 years. Patients receiving atenolol tended to have a lower risk of stroke than patients on placebo; one study showed a 43% reduction in stroke risk, but most patients in that study were treated with more than one antihypertensive drug. All the studies showed a marked reduction in blood pressure using atenolol.

The authors also carried out a meta-analysis of five trials (17,671 patients) comparing atenolol with other antihypertensive agents. Although atenolol showed similar efficacy to the other drugs in terms of blood-pressure lowering, there was significantly higher mortality in the atenolol group during the mean follow-up of 4.6 years. Importantly, cardiovascular mortality was higher in the atenolol group, as was the risk of stroke.

Carlberg et al. conclude that the suitability of atenolol as an antihypertensive agent is now uncertain. Its role as a reference drug in trials of antihypertensive agents might no longer be appropriate.