Current hypertension guidelines generally start with one of the following medication classes: an ACE inhibitor or ARB, a thiazide-type diuretic, or a calcium channel blocker.1 Beta blockers are typically used when there are specific indications (such as coronary disease, certain arrhythmias, or heart failure) or as an add-on later, depending on the patient.1,17 While ACE inhibitors and ARBs generally provide strong cardiovascular protection, renal preservation in appropriate patients, and reduction in left ventricular hypertrophy, prescribing patterns can still drift toward familiar or less strategic agents rather than the most indication-driven choice.1–4 We take a more strategic approach.
Our preferred first-line agent is telmisartan, which offers distinctive metabolic and organ-protective advantages compared with many other ARBs.5–10 Beyond blood pressure reduction, telmisartan provides insulin sensitization through PPAR-γ activation, has the longest half-life of any ARB (supporting true 24-hour coverage), offers robust cardiovascular and renal protection, and demonstrates anti-inflammatory and adipokine-modulating effects.5–10 Through these means, it is uniquely metabolically positive, making it ideal for patients with diabetes or metabolic syndrome.6,7
If blood pressure remains uncontrolled, we add amlodipine, a well-tolerated calcium channel blocker with proven cardiovascular benefits.1,11 If additional therapy is needed, we tailor the next add-on to the patient. Thiazide-type diuretics remain an effective, evidence-based option (with electrolyte and metabolic monitoring), while a cardioselective beta blocker may be preferred in selected patients, especially when tachycardia, angina, arrhythmias, heart failure, or intolerance to a diuretic is part of the picture.1,12,13,17 Our preferred agent is bisoprolol, a highly cardioselective (β1-selective) beta blocker with proven cardiovascular mortality benefits in HFrEF, once-daily dosing, and a lower side effect burden than older non-selective beta blockers.14–17 Bisoprolol is also less likely to adversely affect lipid or glucose metabolism than older, less selective beta blockers.16,17
References
Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. 2025;82(10):e212-e316. doi:10.1161/HYP.0000000000000249
Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int. 2021;99(3S):S1-S87. doi:10.1016/j.kint.2020.11.003
Klingbeil AU, Schneider M, Martus P, Messerli FH, Schmieder RE. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med. 2003;115(1):41-46. doi:10.1016/S0002-9343(03)00158-X
Derington CG, Berchie RO, Mohanty AF, et al. First-line β-blocker use for hypertension in the Veterans Health Administration. JAMA Netw Open. 2025;8(8):e2529026. doi:10.1001/jamanetworkopen.2025.29026
Benson SC, Pershadsingh HA, Ho CI, et al. Identification of telmisartan as a unique angiotensin II receptor antagonist with selective PPAR-γ-modulating activity. Hypertension. 2004;43(5):993-1002. doi:10.1161/01.HYP.0000123072.34629.57
Imenshahidi M, Roohbakhsh A, Hosseinzadeh H. Effects of telmisartan on metabolic syndrome components: a comprehensive review. Biomed Pharmacother. 2024;171:116169. doi:10.1016/j.biopha.2024.116169
Suksomboon N, Poolsup N, Prasit T. Systematic review of the effect of telmisartan on insulin sensitivity in hypertensive patients with insulin resistance or diabetes. J Clin Pharm Ther. 2012;37(3):319-327. doi:10.1111/j.1365-2710.2011.01295.x
Yusuf S, Teo KK, Pogue J, et al; ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358(15):1547-1559. doi:10.1056/NEJMoa0801317
Bakris G, Burgess E, Weir MR, Davidai G, Koval S; AMADEO Study Investigators. Telmisartan is more effective than losartan in reducing proteinuria in patients with diabetic nephropathy. Kidney Int. 2008;74(3):364-369. doi:10.1038/ki.2008.204
Micardis (telmisartan) tablets [prescribing information]. Boehringer Ingelheim Pharmaceuticals, Inc.; 2009.
Dahlöf B, Sever PS, Poulter NR, et al; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366(9489):895-906. doi:10.1016/S0140-6736(05)67185-1
Sica DA, Carter B, Cushman W, Hamm L. Thiazide and loop diuretics. J Clin Hypertens (Greenwich). 2011;13(9):639-643. doi:10.1111/j.1751-7176.2011.00512.x
Mukete BN, Rosendorff C. Effects of low-dose thiazide diuretics on fasting plasma glucose and serum potassium: a meta-analysis. J Am Soc Hypertens. 2013;7(6):454-466. doi:10.1016/j.jash.2013.05.004
CIBIS-II Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353(9146):9-13. doi:10.1016/S0140-6736(98)11181-9
Bisoprolol fumarate tablet [prescribing information]. DailyMed, National Library of Medicine. Accessed May 25, 2026. https://dailymed.nlm.nih.gov/
Marti HP, Pavía López AA, Schwartzmann P. Safety and tolerability of β-blockers: importance of cardioselectivity. Curr Med Res Opin. 2024;40(sup1):55-62. doi:10.1080/03007995.2024.2317433
Best Practice Advocacy Centre New Zealand. Beta blockers for cardiovascular conditions: one size does not fit all. Published June 7, 2024. Accessed May 25, 2026. https://bpac.org.nz/2024/beta-blockers.aspx
No responses yet