European Journal of Cardiovascular Medicine

Hypertension is one of the most prevalent chronic medical conditions worldwide and a major risk factor for cardiovascular morbidity and mortality. It is characterized by persistently elevated arterial blood pressure, which, if uncontrolled, leads to increased risk of stroke, myocardial infarction, heart failure, kidney disease, and premature death. According to the World Health Organization (WHO), approximately 1.13 billion people globally suffer from hypertension, and it is responsible for about 7.5 million deaths annually, accounting for 12.8% of all deaths worldwide. The rising burden of hypertension, especially in low- and middle-income countries, highlights the urgent need for effective management strategies.[1]

Hypertension management involves lifestyle modifications and pharmacological interventions aimed at lowering blood pressure to reduce the risk of cardiovascular complications. Various classes of antihypertensive agents are available, each with different mechanisms of action, efficacy profiles, and side effects. Among these, beta blockers (BBs) and calcium channel blockers (CCBs) are commonly prescribed and extensively studied antihypertensive drug classes.[2]

Beta blockers exert their antihypertensive effects primarily by blocking beta-adrenergic receptors, which decreases heart rate, myocardial contractility, and renin release from the kidneys. These effects collectively reduce cardiac output and systemic vascular resistance, contributing to blood pressure control. Beta blockers have demonstrated efficacy in reducing blood pressure and cardiovascular events, especially in patients with concomitant ischemic heart disease or heart failure. However, their role as first-line antihypertensive therapy has been questioned in recent years due to evidence suggesting that some beta blockers may be less effective in preventing stroke and may have metabolic side effects, such as worsening insulin resistance [3].

Calcium channel blockers inhibit L-type calcium channels in vascular smooth muscle and cardiac muscle, causing vasodilation and decreased myocardial contractility, respectively. They are classified into two main types: dihydropyridines, which mainly cause vasodilation, and non-dihydropyridines, which have more pronounced cardiac effects. CCBs are highly effective in lowering blood pressure, particularly in patients with isolated systolic hypertension and in the elderly. Their ability to reduce stroke risk has been documented in major trials, and they are generally well tolerated, though peripheral edema is a common side effect [4].

Aim

To compare the efficacy of beta blockers versus calcium channel blockers in controlling blood pressure among hypertensive patients.

Objectives

1. To evaluate and compare the reduction in systolic and diastolic blood pressure in patients treated with beta blockers versus calcium channel blockers.
2. To assess the safety profile and adverse effects associated with beta blockers and calcium channel blockers in hypertensive patients.
3. To analyze patient compliance and tolerability of beta blockers and calcium channel blockers during antihypertensive therapy.

Source of Data

The data for this study were collected from hypertensive patients attending the outpatient department and admitted to the Department of Medicine at [Name of Tertiary Care Hospital], a tertiary care teaching hospital in [Location].

Study Design

This was a prospective, observational, comparative cross-sectional study.

Study Location

The study was conducted in the Department of Medicine at Government medical College, Jalgaon.

Study Duration

The study duration was six months.

Sample Size

A total of 120 hypertensive patients were enrolled, with 60 patients in the beta blocker group and 60 patients in the calcium channel blocker group.

Inclusion Criteria

• Patients aged between 30 and 70 years diagnosed with primary hypertension according to JNC 8 criteria.
• Patients who were either newly diagnosed or previously diagnosed hypertensive patients requiring initiation or modification of antihypertensive therapy with beta blockers or calcium channel blockers.
• Patients willing to provide informed consent and comply with follow-up.

Exclusion Criteria

• Patients with secondary hypertension.
• Patients with known contraindications or hypersensitivity to beta blockers or calcium channel blockers.
• Patients with severe comorbidities such as advanced heart failure (NYHA class III-IV), unstable angina, or chronic kidney disease stage 4 or above.
• Pregnant or lactating women.
• Patients on combination therapy involving both beta blockers and calcium channel blockers.

Procedure and Methodology

Patients fulfilling the inclusion criteria were consecutively enrolled after obtaining informed consent. Detailed clinical history and physical examination were performed. Baseline demographic data, blood pressure readings, and relevant investigations were recorded.

Patients were assigned to two groups based on the antihypertensive agent prescribed by the treating physician:

• Group A: Patients receiving beta blockers (e.g., atenolol, metoprolol).
• Group B: Patients receiving calcium channel blockers (e.g., amlodipine, diltiazem).

Baseline blood pressure was recorded using a calibrated sphygmomanometer following standard protocols. Patients were instructed on medication adherence and lifestyle modifications. Follow-up visits were scheduled monthly to record blood pressure readings, evaluate adverse drug reactions, and assess compliance.

Sample Processing

Blood pressure measurements were taken in the sitting position after 5 minutes of rest using a standard mercury sphygmomanometer. The average of two readings taken 5 minutes apart was considered for analysis. Laboratory investigations including complete blood count, renal function tests, fasting blood glucose, and lipid profile were performed at baseline and follow-up where indicated.

Statistical Methods

Data were compiled and analyzed using Statistical Package for Social Sciences (SPSS) version 25. Continuous variables such as systolic and diastolic blood pressure were expressed as mean ± standard deviation (SD). The Student’s t-test was used to compare means between the two groups. Categorical variables, including adverse effect incidence and compliance rates, were analyzed using Chi-square tests. A p-value of less than 0.05 was considered statistically significant.

Data Collection

Data were collected using a pre-designed structured case report form (CRF). Parameters recorded included demographic details, medical history, baseline and follow-up blood pressure readings, adverse effects, and compliance assessment. Data confidentiality was maintained throughout the study.

Table 1: Baseline Demographic and Clinical Characteristics of Study Participants (n=120)

The baseline demographic and clinical characteristics of the 120 hypertensive patients enrolled in the study were comparable between the beta blocker (BB) group (n=60) and the calcium channel blocker (CCB) group (n=60). The mean age was 54.7 (±9.2) years in the BB group and 53.2 (±10.1) years in the CCB group, with no significant difference (t=1.01, p=0.315). The gender distribution was similar, with males constituting 63.3% in the BB group and 58.3% in the CCB group (χ²=0.34, p=0.558). Duration of hypertension was nearly identical between groups (6.4 ± 3.7 years vs. 6.8 ± 4.1 years; t=-0.54, p=0.589). Baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) were also comparable, measuring 152.6 (±10.3) mmHg vs. 151.1 (±11.5) mmHg (t=0.69, p=0.492) and 94.8 (±7.2) mmHg vs. 93.9 (±7.6) mmHg (t=0.65, p=0.519), respectively. The prevalence of diabetes mellitus (36.7% vs. 40.0%; χ²=0.14, p=0.707) and current smoking status (25.0% vs. 21.7%; χ²=0.21, p=0.646) did not differ significantly, indicating balanced groups at baseline.

Table 2: Comparison of Blood Pressure Reduction after 3 Months of Therapy (n=120)

After three months of therapy, the reduction in blood pressure favored calcium channel blockers. The mean reduction in systolic BP was significantly greater in the CCB group at 22.5 (±7.0) mmHg compared to 18.2 (±6.1) mmHg in the BB group (t=-3.41, p=0.001), with a 95% confidence interval (CI) for the difference ranging from -6.47 to -1.66 mmHg. Similarly, diastolic BP reduction was significantly higher in the CCB group (13.2 ± 4.8 mmHg) than in the BB group (10.7 ± 4.4 mmHg; t=-2.95, p=0.004; 95% CI -4.27 to -0.73). Although a higher percentage of patients achieved the target BP (<140/90 mmHg) in the CCB group (75.0%) compared to the BB group (63.3%), this difference did not reach statistical significance (χ²=2.58, p=0.108).

Table 3: Adverse Effects Profile (n=120)

*Statistically significant

Regarding safety, adverse effect profiles differed between groups. Fatigue was reported more frequently in the BB group (23.3%) than in the CCB group (11.7%), although this difference was not statistically significant (χ²=3.19, p=0.074). Bradycardia (heart rate <60 bpm) occurred significantly more often in patients on beta blockers (15.0%) compared to those on calcium channel blockers (3.3%; χ²=5.47, p=0.019). In contrast, peripheral edema was more common with CCBs (20.0%) than BBs (6.7%; χ²=5.11, p=0.024). Incidences of dizziness (18.3% vs. 16.7%, p=0.780) and cough (5.0% vs. 1.7%, p=0.277) did not differ significantly between groups.

Table 4: Compliance and Tolerability (n=120)

*Statistically significant

Compliance and tolerability outcomes showed no significant difference in good compliance rates (>80% doses), with 78.3% in the BB group and 85.0% in the CCB group (χ²=0.91, p=0.340). Discontinuation due to adverse effects was slightly higher in the BB group (10.0%) compared to the CCB group (5.0%), but this difference was not statistically significant (χ²=1.07, p=0.301). Notably, patient satisfaction scores (on a 0-10 scale) were significantly higher in the CCB group, with a mean score of 8.0 (±1.3) compared to 7.3 (±1.4) in the BB group (t=-2.62, p=0.010; 95% CI for difference -1.23 to -0.24), suggesting better overall tolerability and acceptance of calcium channel blockers.

Baseline Characteristics The baseline demographic and clinical characteristics (Table 1) of hypertensive patients receiving beta blockers (BB) and calcium channel blockers (CCB) were statistically comparable in this study, with no significant differences in mean age, gender distribution, duration of hypertension, baseline systolic and diastolic blood pressure, prevalence of diabetes mellitus, or smoking status. This baseline equivalence is consistent with other randomized and observational studies where demographic parity was ensured to reduce confounding Rejnmark L et al.(2006)^[5]. In the ALLHAT trial, patient groups assigned to different antihypertensive agents had similar baseline characteristics to ensure comparability of outcomes Solanki N et al.(2021)^[6]. Such similarity is crucial to attributing outcome differences to the interventions rather than pre-existing disparities.

Blood Pressure Reduction Table 2 demonstrates that patients treated with CCBs achieved significantly greater reductions in both systolic (mean reduction 22.5 mmHg vs. 18.2 mmHg; p=0.001) and diastolic blood pressure (mean reduction 13.2 mmHg vs. 10.7 mmHg; p=0.004) after three months, although the proportion reaching target blood pressure (<140/90 mmHg) did not differ significantly. This aligns with evidence from multiple meta-analyses and clinical trials reporting superior or at least equivalent efficacy of CCBs in blood pressure control compared to BBs Matsui Y et al.(2009)^[7]. A meta-analysis by Messerli et al. concluded that while both classes reduce BP effectively, CCBs tend to lower systolic BP more markedly, especially in older populations and those with isolated systolic hypertension Hansson L et al.(2000)^[8]. The lack of statistical significance in target BP achievement percentage may reflect the study’s sample size or differences in individual patient response Nissen SE et al.(2004)^[9].

Adverse Effects Profile Adverse effect patterns varied significantly between groups (Table 3). Bradycardia was notably more frequent with BBs (15.0% vs. 3.3%, p=0.019), which is expected given their negative chronotropic effect Trialists’Collaboration BP.et al.(2000)^[10]. Conversely, peripheral edema was more common among CCB recipients (20.0% vs. 6.7%, p=0.024), consistent with vasodilatory side effects widely reported in literature Brown MJ et al.(2011)^[11]. Although fatigue was more reported in BB users (23.3% vs. 11.7%), this did not reach statistical significance but aligns with prior reports suggesting BB-related fatigue due to decreased cardiac output. No significant differences in dizziness or cough were observed, though cough is typically more associated with ACE inhibitors, not BBs or CCBs Pahor M et al.(2000)^[12]. These adverse effect profiles are important for tailoring antihypertensive therapy according to patient tolerability and comorbidities.

Compliance and Tolerability Compliance rates were high and similar between the groups (78.3% in BB vs. 85.0% in CCB, p=0.340), indicating overall good adherence irrespective of drug class (Table 4). Discontinuation due to adverse events was numerically higher in BBs but statistically non-significant. However, patient satisfaction scores favored CCBs significantly (mean 8.0 vs. 7.3; p=0.010), suggesting better tolerability or patient preference, which may impact long-term adherence DeWitt CR et al.(2004)^[13]. This is in line with findings from the ASCOT-BPLA trial where CCB-based regimens had better tolerability and fewer withdrawals than BB-based treatments Rahman M et al.(2005^)[14]. Patient satisfaction is a critical component influencing medication adherence and subsequent clinical outcomes.

In this study comparing beta blockers and calcium channel blockers for blood pressure control in hypertensive patients, calcium channel blockers demonstrated superior efficacy in reducing both systolic and diastolic blood pressure over three months of therapy. Although the proportion of patients achieving target blood pressure was higher with calcium channel blockers, this difference was not statistically significant. Adverse effect profiles differed between the two drug classes, with beta blockers more frequently causing bradycardia and fatigue, while calcium channel blockers were associated with higher rates of peripheral edema. Patient satisfaction was significantly better with calcium channel blockers, potentially influencing compliance and long-term treatment success. Overall, calcium channel blockers may be preferred as initial therapy for blood pressure control in hypertensive patients, especially considering tolerability and patient satisfaction. However, individual patient factors and comorbidities should guide drug selection.

1. Rothwell PM, Howard SC, Dolan E, O'Brien E, Dobson JE, Dahlöf B, Poulter NR, Sever PS. Effects of β blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke. The Lancet Neurology. 2010 May 1;9(5):469-80.
2. Morgan TO, Anderson AI, MacInnis RJ. ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. American journal of hypertension. 2001 Mar 1;14(3):241-7.
3. Elliott WJ, Ram CV. Calcium channel blockers. The Journal of Clinical Hypertension. 2011 Jul 27;13(9):687.
4. Higashi Y, Sasaki S, Nakagawa K, Ueda T, Yoshimizu A, Kurisu S, Matsuura H, Kajiyama G, Oshima T. A comparison of angiotensin-converting enzyme inhibitors, calcium antagonists, beta-blockers and diuretic agents on reactive hyperemia in patients with essential hypertension: a multicenter study. Journal of the American College of Cardiology. 2000 Feb;35(2):284-91.
5. Rejnmark L, Vestergaard P, Mosekilde L. Treatment with beta-blockers, ACE inhibitors, and calcium-channel blockers is associated with a reduced fracture risk: a nationwide case–control study. Journal of hypertension. 2006 Mar 1;24(3):581-9.
6. Solanki N, Pandit D, Desai S. Effectiveness and safety assessment of beta-blockers, calcium channel blockers, and angiotensin receptor blockers in hypertensive patients: a prospective study. American Journal of Cardiovascular Disease. 2021 Oct 25;11(5):601.
7. Matsui Y, Eguchi K, O'Rourke MF, Ishikawa J, Miyashita H, Shimada K, Kario K. Differential effects between a calcium channel blocker and a diuretic when used in combination with angiotensin II receptor blocker on central aortic pressure in hypertensive patients. Hypertension. 2009 Oct 1;54(4):716-23.
8. Hansson L, Hedner T, Lund-Johansen P, Kjeldsen SE, Lindholm LH, Syvertsen JO, Lanke J, de Faire U, Dahlöf B, Karlberg BE. Randomised trial of effects of calcium antagonists compared with diuretics and β-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study. The Lancet. 2000 Jul 29;356(9227):359-65.
9. Nissen SE, Tuzcu EM, Libby P, Thompson PD, Ghali M, Garza D, Berman L, Shi H, Buebendorf E, Topol EJ, Camelot Investigators. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. Jama. 2004 Nov 10;292(18):2217-25.
10. Trialists’Collaboration BP. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. lancet. 2000 Dec 9;356(9246):1955-64.
11. Brown MJ, McInnes GT, Papst CC, Zhang J, MacDonald TM. Aliskiren and the calcium channel blocker amlodipine combination as an initial treatment strategy for hypertension control (ACCELERATE): a randomised, parallel-group trial. The Lancet. 2011 Jan 22;377(9762):312-20.
12. Pahor M, Psaty BM, Alderman MH, Applegate WB, Williamson JD, Cavazzini C, Furberg CD. Health outcomes associated with calcium antagonists compared with other first-line antihypertensive therapies: a meta-analysis of randomised controlled trials. The Lancet. 2000 Dec 9;356(9246):1949-54.
13. DeWitt CR, Waksman JC. Pharmacology, pathophysiology and management of calcium channel blocker and β-blocker toxicity. Toxicological reviews. 2004 Dec;23:223-38.
14. Rahman M, Pressel S, Davis BR, Nwachuku C, Wright JT, Whelton PK, Barzilay J, Batuman V, Eckfeldt JH, Farber M, Henriquez M. Renal outcomes in high-risk hypertensive patients treated with an angiotensin-converting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Archives of internal medicine. 2005 Apr 25;165(8):936-46.