Abstract: We included 25 RCTs that evaluated the BP lowering effects of seven nonselective beta-blockers in 1264 people with hypertension. Among the 25 RCTs, four were parallel studies and 21 were cross-over studies. Overall, nonselective beta-blockers lowered systolic BP and diastolic BP compared with placebo. Nonselective beta-blockers, in the recommended dose range, did not showed a convincing dose-response relationship by direct comparison. The once (1x) and twice (2x) starting dose subgroups contained the largest sample size. The estimate of BP lowering efficacy for nonselective beta-blockers by combining the 1x and 2x starting dose subgroup was -10 mmHg (95% CI -11 to -8) for systolic BP and -7 mmHg (95% CI -8 to -6) for diastolic BP (low-quality evidence). Nonselective beta-blockers starting at the 1x recommended starting doses lowered heart rate by 12 beats per minute (95% CI 10 to 13) (low-quality evidence). The dose-response relationship in heart rate was evident by both direct and indirect comparison. Due to imprecision, there was no clear evidence of an effect of nonselective beta-blockers on pulse pressure in any dose subgroups except for a small reduction with the 2x starting dose (-2.2 mmHg, 95% CI -3.7 to -0.7) (very low quality evidence). The point estimates in the 1x, four times (4x) and eight times (8x) starting dose subgroups were similar to the 2x starting dose subgroup. Therefore, it would appear that if nonselective beta-blockers do lower pulse pressure, the magnitude is likely to be about 2 mmHg. There were very limited data (two studies) on withdrawals due to adverse effects (risk ratio (RR) 0.84; 95% CI 0.38 to 1.82). In people with mild-to-moderate hypertension, nonselective beta-blockers lowered peak BP by a mean of -10/-7 mmHg (systolic/diastolic) and reduced heart rate by 12 beats per minute. Propranolol and penbutolol were the two drugs that contributed to most of the data for nonselective beta-blockers. This estimate is likely exaggerated due to the presence of extreme outliers and other sources of bias. If we removed the extreme outliers from the analysis, the estimate for non-selective beta-blockers was lower (-8/-5 mmHg (systolic/diastolic)). Nonselective beta-blockers did not show a convincing graded dose-response in the recommended dose range for systolic BP and diastolic BP, while higher dose nonselective beta-blockers provided greater reduction of heart rate. Using higher dose nonselective beta-blockers might cause more side effects, such as bradycardia, without producing an additional BP lowering effect. The effect of nonselective beta-blockers on pulse pressure was likely small, at about 2 mmHg.

Plain-language summary: We developed a comprehensive search strategy of all relevant scientific databases to identify all clinical trials to answer this question. Participants had to have a baseline systolic blood pressure (the top number of a blood pressure reading) of at least 140 mmHg or a diastolic blood pressure (the bottom number of a blood pressure reading) of at least 90 mmHg, or both of these. We did not restrict participants by age, gender, baseline risk or any other medical conditions. We found 25 clinical trials that compared the blood pressure lowering effect of seven nonselective beta-blockers with placebo in 1264 people with high blood pressure. On average, nonselective beta-blockers lowered blood pressure by about 10 mmHg systolic and 7 mmHg diastolic, and reduced heart rate by 12 beats per minute. This estimate is likely greater than the true effect because of biases in the running and reporting of the trials. We did not find convincing evidence that higher doses of nonselective beta-blockers lowered blood pressure more than lower doses. However, higher doses of nonselective beta-blockers significantly lowered heart rate compared with lower doses, which could lead to more side effects. Since the blood pressure lowering effect for systolic is similar to the blood pressure lowering effect of diastolic, the effect of this subclass on pulse pressure (the difference between systolic and diastolic) was small at about 2 mmHg. The quality of the evidence is low due to the presence of extreme outliers and high risk of biases.