Beta Blockers vs. ACE Inhbitors

[Lavndrrose]

Why would a physician decide to switch his patient from beta blockers to ACE inhibitors for the treatment of hypertension? Is there any special reason for this? Please...can someone help me? Thanks!

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[ckent]

beta blockers are usually not considered first line therapy for a lot of patients unless they have congestive heart failure or have coronary heart disease. One of the reasons for this is because a lot of patients don't like beta blockers because it makes them drowsy (people hate taking a medicine that makes them feel worse for a medical condition that doesn't make them feel bad at all to begin with), and some patients (diabetics) have difficulty tolerating betablockers because it prevents them from realizing that they are hypoglycemic. Another relative contraindication would be poorly controlled asthmatics. Mortality studies have been more favorable for using ACE's and Hctz for otherwise healthy patients as well. Anyways, for all of those reasons and more, in healthy people with only high blood pressure, hctz (a diuretic) would be first line therapy, but some could also advocate usage of an ACE inhibitor for first line therapy depending on the patient. And of course, another reason could have just been that their high blood pressure wasn't being controlled by the beta blocker so their doctor decided to try switching them to an ACE alone because their blood pressure wasn't all that elevated and their doctor read some of the more recent studies regarding ACE's and has been gradually switching all of his/her patients to be consistent with the latest studies. Anyways, I assume that this is for a friend or family member, so my advice would be to just tell that person to ask their doctor why they were switched as they have a right to know. It always amazes me how many people would ask the mechanic what was wrong with their car if it broke down and the mechanic wanted to fix it, but don't seem to ask about their health.

 

[Lavndrrose]

thanks so much for the reply, ckent. is it okay to suddenly switch from beta blocker to ACE inhibitor? Meaning...does the body respond well to this sudden change? thanks

 

[ckent]

Yes, it's usually fine to "suddenly" switch. They should just have their blood pressure checked periodically to make sure that it doesn't suddenly go too high, and someone should check their electrolytes in their blood in a couple of weeks as well. If you're a med student, I'd recc practicing checking their blood pressure for them. I wouldn't expect their blood pressure to go down for a couple of days though after starting the ACE.

 

[DR]

Additional reasons to switch exist, though they are more complex. For example, if the person taking the beta blocker started becoming bradycardic, or if they were borderline brady and the pressure was still too high, then they could not increase the beta blocker anymore and they switch. Additionally, if someone develops diabetes or renal disease, often ACE inhibitors are utilized now because of their known renal protective effects, and their ability to prevent the progression of proteinuria.
With all this said, it is usually the practice of most docs not to switch once something is working, unless there is a problem (like a bad side effect or there is a new diagnosis of diabetes), so I think the likelihood that the doctor did it to just follow the trends in the literature is probably less likely. But CKent has nicely outlined most of the points regarding beta blockers vs. ACE inhibitors. One last note (though it may not be something you wanna hear if it's a relative) is that males are often switched if they start to display one of the famous side effects of beta blockers: erectile dysfunction.

 

[jashanley]

Beta blockers and diuretics are considered first line therapy for HTN. I agree betablockers can and sometimes do make patients feel terrible but so do diuretics. Especially when they are up all night peeing and can't get a good nights sleep.
It is improtant to remember the mechanism behind beta blocker control of high blood pressure. It is primarily control of HR which decreases the BP. So if someone is already bradycardic, then starting a beta blocker won't do much to control HTN.
I do like diuretics, specifically HCTZ in my newly diagnosed patient's with HTN. But I also love beta blockers overall.
All diabetics in theory should be on an ace for renal protection. However, I find that with regards to BP control it doesn't provide patients with a lot of control. There is some decrease but most patients only have minimal changes despite max doses.

 

[ckent]

Originally posted by jashanley
Beta blockers and diuretics are considered first line therapy for HTN. I agree betablockers can and sometimes do make patients feel terrible but so do diuretics. Especially when they are up all night peeing and can't get a good nights sleep.

Only Furosemide or loop diuretics should cause patients to pee a lot, pt's should pee a lot in the beginning of Hctz therapy but they should eventually equilibriate and pee no more then normally. If they are peeing more then usual on Hctz, it's either their imagination or they are eating a *lot* of salt (which will probably make them hypokalemic before it causes them to pee too much too). I also recall reading that ACE's only lower BP by about 10-15 mmHg. I think that's around how much most anti-htn's lower BP though.

 

[jashanley]

My patients in clinic complain of peeing all night long--no matter what diuretic they are on. Sure, loop diuretics seem cause more urination but I find my patients notice it with all of them.

 

[ckent]

Originally posted by jashanley
My patients in clinic complain of peeing all night long--no matter what diuretic they are on. Sure, loop diuretics seem cause more urination but I find my patients notice it with all of them.

Well, I did a brief literature search and could not find any literature that suggested that thiazide diuretics do not cause increased urine output after being on them a long time. The nephrologist that I was just working with told me that though, he said that Hctz causes overall volume status to decrease and stay decreased, thus after patients lose the volume, they pee normally. Furosemide on the otherhand, leads to fluctations in patients volume, meaning that as the drug is metabolized, patients regain some of the volume that they lost and then re-urinate out the volume after taking their next dosage. If I find any literature suggesting this or disputing it, I will post it. My attending has been wrong about things in the past.

 

[Eidolon6]

Once you tell a patient you are giving them a diuretic...they will become much more aware of their bathroom habits. Remember too that though HCTZ is considered first line, few patients will just require the single agent. Ultimately, they end up on another agent, but at a lower dose...which for Beta blockers is a good thing since they do have a significant side effect profile.

Unfortunately, I seem more and more patients started first on calcium channel blockers like Norvasc. This is really the wrong approach. I have "cured" some apparent heart failure just by discontinuing peoples overdosed calcium channel blockers. Additionally, Ca channel blockers, unlike ACEI/ARBS provide no renoprotective benefit in diabetics and in some series have actually contributed to more rapid decline in renal function.

 

[ckent]

Also, don't forget that CCB's can actually cause edema, rather then taking it away. I worked with an FP that seemed to be using random anti-htn's as first line therapies for patients with no real co-morbidities too. One patient was finally switched from norvasc to hctz after he actually read a news report on the new hctz study that came out last year and asked to be switched. Kind of sad if a patient is more up to date then the doctor.

 

[DrQuinn]

Originally posted by Eidolon6


Unfortunately, I seem more and more patients started first on calcium channel blockers like Norvasc. This is really the wrong approach. I have "cured" some apparent heart failure just by discontinuing peoples overdosed calcium channel blockers. Additionally, Ca channel blockers, unlike ACEI/ARBS provide no renoprotective benefit in diabetics and in some series have actually contributed to more rapid decline in renal function.

One of the best ways to "protect" the kidneys of a diabetic is overall hypertension control. If you use a Ca Channel blocker to lower their blood pressure, even though it doesn't have the physiologic protective effects of teh ACE/ARBS, you WILL lower their rate of renal failure compared to the control group. It is the absolute blood pressure that is key to preventing proteinuria -> failure along with the ACEs.

Q, DO

 

[Eidolon6]

Originally posted by QuinnNSU
One of the best ways to "protect" the kidneys of a diabetic is overall hypertension control. If you use a Ca Channel blocker to lower their blood pressure, even though it doesn't have the physiologic protective effects of teh ACE/ARBS, you WILL lower their rate of renal failure compared to the control group. It is the absolute blood pressure that is key to preventing proteinuria -> failure along with the ACEs.

Q, DO

Managment of HTN is the crux of good protection of the kidneys (that goes without saying), however, the ACEI/ARB mechanism for reducing proteinuria is independent of systolic and diastolic BP in diabetics. A normotensive diabetic will gain no benefit from BP reduction with any agent, however, they will gain benefit from ACEI/ARB by influence on the Renin-angiotensin axis. Circulation. 2002 Aug 6;106(6):643-5.

I direct you to the AASK trial. JAMA. 2002 Nov 20;288(19):2421-31.