Should atenolol still be recommended as first-line therapy for primary hypertension?

antihypertensive treatment should reduce the incidence of cardiovascular morbidity and mortality as well as total mortality. For four decades, beta-blockers have been widely used for the treatment of hypertension and are still proposed as first-line drugs in national and international guidelines. Numerous prospective, randomised studies have established beyond any doubt the efficacy of beta-blockers in patients with coronary artery disease (angina or history of myocardial infarction), congestive heart failure or hypertrophic cardiomyopathy. Newer vasodilating drugs, such as carvedilol, bisoprolol and nebivolol, which have a more favorable haemodynamic profile, may be more beneficial. This view is supported by the Carvedilol or Metoprolol European Trial (COMET) study in patients with congestive heart failure, in which carvedilol was superior to metoprolol in reducing morbidity and mortality. However, the efficacy of beta-blockers in the treatment of primary hypertension has been challenged. Studies with betablockers apart from atenolol are surprisingly few, with few clinical events, so the results are inconclusive. Moreover, atenolol is one of the most popular beta-blockers and has often been used as a reference drug in randomised controlled trials in arterial hypertension. During the last four years, three mega-trials have been published comparing atenolol to active antihypertensive treatment. Hence, the aim of this study was to systematically review and analyse the effect of atenolol on cardiovascular and allcause mortality, stroke and myocardial infarction in hypertensive patients.