First-Line ß-Blocker Use for Hypertension in the Veterans Health Administration.

Derington CG, Berchie RO, Mohanty AF, Jacobs JA, Xu Y, King JB, Rethy L, Cushman WC, Zickmund SL, Ho PM, Raghavan S, Cohen JB, Bress AP. First-Line ß-Blocker Use for Hypertension in the Veterans Health Administration. JAMA Network Open. 2025 Aug 1; 8(8):e2529026, DOI: 10.1001/jamanetworkopen.2025.29026.

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Abstract:

IMPORTANCE: Starting in 2014, US guidelines have not recommended ß-blockers for first-line treatment of hypertension in the absence of compelling indications due to their tolerability profile and inferior protection against stroke and mortality compared with other first-line agents. The prevalence and factors associated with this guideline-discordant practice are unknown. OBJECTIVE: To estimate the prevalence of and factors associated with first-line ß-blocker use among those without compelling indications for a ß-blocker. DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional study of new users of antihypertensive medications using national, patient-level data in the Veterans Health Administration between January 1, 2000, and December 31, 2022. Patients were veterans initiating antihypertensive medications for newly diagnosed hypertension in the outpatient setting based on diagnosis codes and prescription dispenses, excluding veterans without a primary care visit in the prior year. EXPOSURE: Initiation of antihypertensive medications for newly diagnosed hypertension. MAIN OUTCOMES AND MEASURES: Among those without compelling indications (ie, aortic aneurysm and/or disease, angina, atrial fibrillation or arrhythmia, chronic liver disease or cirrhosis, heart failure with reduced ejection fraction, myocardial infarction, or coronary revascularization), multivariable Poisson regression was used to estimate factors associated with ß-blocker initiation. RESULTS: Of 3?138?304 included veterans (mean [SD] age 61.0 [13.0] years, 2?958?488 [94.3%] male, 149?807 [4.8%] Hispanic, 490?636 [15.6%] non-Hispanic Black, 2?028?127 [64.6%] non-Hispanic White, and and 66?798 [2.1%] other races and ethnicities ), 774?821 (24.7%) initiated a ß-blocker. Overall, 684?045 patients (88.2%) who initiated a ß-blocker did not have compelling indications, which decreased over time from 245?703 (91.8%) in 2000 through 2005 to 93?088 (81.5%) in 2018 to 2022. Metoprolol and carvedilol were the most commonly initiated ß-blockers and increased over time, and atenolol initiation decreased over time. Among other factors, a greater prevalence ratio for ß-blocker initiation was observed among older (PR, 1.05; 95% CI, 1.04-1.05), female (PR, 1.11; 95% CI, 1.09-1.14), non-Hispanic White (as reference group; Non-Hispanic Black PR, 0.74; 95% CI, 0.73-0.76; Hispanic PR, 0.75; 95% CI, 0.73-0.77; all others PR, 0.89; 95% CI, 0.86-0.92) or frail veterans (PR, 1.28; 95% CI, 1.25-1.31). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, most veterans using ß-blockers as a first-line treatment for hypertension did not have compelling indications, and several factors were associated with likelihood of ß-blocker initiation in this group. Interventions are needed to improve initial guideline-concordant treatment for veterans with incident hypertension.