Link: Do Beta-blockers Have a Role in Hypertension Any Longer?. (might need Medscape subscription)
Oh man…Ever since I read Lindholm’s meta-analysis about betablockers for hypertension, I’ve been easing people off of them. With those I think still medically needed them (heart disease, etc.), I switched to metoprolol (mainly SR), but with many of my patients in whom it would be appropriate to switch off, we’re already struggling to find a medication that doesn’t cause them side effects…so keeping them on atenolol/other betablocker is often the only choice.
My particular concern with this article is the interviewee’s (granted, a big hypertension researcher, who likely keeps better abreast of this field than I) treatment of calcium channel blockers as an equally effective therapy to diuretics and ACE inhibitors. My usual practice is to reserve them as the 4th line agents for the truly medication-sensitive or the difficult to control hypertensives. Recent trials sound like they may be calling this view into question somewhat…
And that brings me (as Stephen Colbert might say) to tonight’s word:
The study of how we know what we know, and whether what we know is valid, and whether you know that they know that I know you know….
As seen in other posts, this blog seems to be where I vent my concerns and frustrations about evidence-based medicine – the case of atenolol and beta-blockers is a perfect example of my concern. We KNEW that beta-blockers and diuretics were the best choice for hypertension, and what’s more…there was very little disagreement amongst the expert panels, evidence-based medicine experts, etc. However, Professor Lindholm, over there in Nordic lands, kept trying to shine light on the beta-blocker studies enough evidence had accumulated and we finally took notice. The most troubling thing about this for us self-proclaimed EBMers is the fact that the old studies are now being "outed" for being flawed…well, why didn’t anyone say anything a LONG TIME AGO!!! Should the individual physician be responsible for personally reviewing each study manuscript ever written on the topic before being comfortable in practice. Even those guideline makers, review writers and meta-analysts whose opinions we generally trusted (because of their methodology, not because of their nice, experienced greying hair) did not convey any concern to us about the betablocker studies…Could it be that they were more concerned with getting physicians to stop prescribing so many calcium-channel blockers? Were they in some sense beholden to the pharmaceutical industries (you gotta wonder…)?
Mammography, hormone replacement therapy, beta-blockers – when is the madness going to end?