2023 ESH Guideline for the Management of Hypertension with specific focus on Beta blockers

The new report of the ESH 2023 guideline includes a greater emphasis on out-of-office BP measurements, addition of potassium supplementation as a lifestyle recommendation, and gives more explicit advice for the use of beta blockers as initial antihypertensive drug therapy. Increased resting heart rate (>80 bpm) is common in hypertension, in which it reflects an increased sympathetic activity. A progressive increase in resting heart rate is accompanied by a progressive increase in the risk of AF, HF and mortality both in the general population and in hypertensive patients. Although in hypertension, the advantage of reducing heart rate is limited to post hoc analysis of RCTs, the available evidence makes treated hypertensive patients with an increased heart rate a clinical phenotype supporting the use of BBs. RCTs and meta-analyses have demonstrated that when compared with placebo, first-generation and second-generation BBs like propranolol, atenolol and metoprolol significantly reduce the risk of stroke, HF and major CV events in hypertensive patients. BBs are recommended in patients with HF, angina, post-MI, AF or in younger hypertensive women of child-bearing potential or planning pregnancy. RCTs with carvedilol, bisoprolol, metoprolol and nebivolol showed improved outcomes in patients with HFrEF.In addition to their compelling use as GDMT in specific diseases, BBs exhibit favourable effects in about 50 clinical conditions including various cardiac diseases less or not related to hypertension, other vascular conditions and non-CV diseases   Reference: 2023 ESH Guidelines for the management of arterial hypertension