blockers switched to first-line therapy in hypertension

In their recent guidelines, the European Society of Hypertension upgraded beta blockers, putting them on equal footing with thiazide diuretics, renin-angiotensin system blockers (eg, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers), and calcium channel blockers. The reason offered for upgrading beta blockers was the observation that they are often used for many other clinical conditions commonly encountered with hypertension. This upgrade would allow for the treatment of two conditions with a single drug (a so-called twofer). In most current national and international hypertension guidelines, beta blockers are only considered to be an alternative when there are specific indications. Compared with the other first-line antihypertensive drug classes, beta blockers are significantly less effective in preventing stroke and cardiovascular mortality. To relegate beta blockers to an inferiority status as previous guidelines have done was based on the evidence in aggregate, and still stands. No new evidence supports the switch of beta blockers back to first-line therapy. We are concerned that this move might lead to widespread harm because of inferior stroke protection.