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Hypertension is a major risk factor for ischemic heart disease, stroke, and heart failure. Even moderate blood pressure (BP) elevation can have a significant impact on outcomes. Maintaining BP within recommended levels significantly reduces the risk of cardiovascular morbidity and mortality. Yet, more than one-third of people receiving treatment for hypertension in the United States have uncontrolled BP. When faced with a patient whose BP is no longer controlled, clinicians need to develop a differential diagnosis of potential contributing factors. These factors may include BP measurement issues, poor adherence to antihypertensive medications, therapeutic inertia on the part of clinicians, lifestyle changes, secondary causes of hypertension, or ingestion of substances that interfere with BP control. Patients who demonstrate a deterioration in BP control should be questioned about adherence, recent changes to diet and lifestyle, signs and symptoms of secondary causes of hypertension, and use of any concomitant medications or other substances that may be known to increase BP or interfere with antihypertensive therapy. Common substances that can interfere with BP control include nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, glucocorticoids, antidepressants, decongestants, alcohol, or other stimulants like cocaine and methamphetamines. Because of the high prevalence of both osteoarthritis and hypertension among elderly people, NSAIDs are a common potential factor in this age group. In the face of worsening BP control, clinicians must actively investigate potential contributing factors and appropriately increase or adjust antihypertensive therapy.

Out-of-hospital sudden cardiac death occurs in approximately 300,000 individuals each year in the United States, a total that represents about half of all annual deaths from coronary heart disease. Beta-blockers were the first class of drugs investigated for the prevention of sudden cardiac arrest because of their ability to reduce ventricular arrhythmias. Numerous randomized, controlled trials have now established the importance of beta-blockade in preventing sudden cardiac death. Clinical evidence reveals the association between beta-blockade and improved survival, and trials explore the role for beta-blockers in the prevention of sudden cardiac death.

Beta-blockers are an established class in the management of hypertension, and numerous randomized, controlled trials have shown that these drugs can prevent cardiovascular events in this population. However, beta-blockers are underutilized in managing the general hypertensive population. This phenomenon may stem in part from concerns about side effects. On the contrary, beta-blockers demonstrate comparable efficacy, safety, and tolerability compared with other classes of antihypertensive drugs. Because beta-blockers offer unique cardiovascular protection, they should be considered an integral part of the treatment regimen for patients with hypertension who are at risk for cardiovascular events.

Data from large clinical trials indicate that beta-blocker therapy can be successfully initiated and adjusted upward in most patients with stable chronic heart failure who already take standard heart failure therapy. Such therapy typically includes ACE inhibitors, diuretics, and digoxin. With optimal titration and maintenance strategies, beta-blockers are effective and well tolerated in these patients. It is recommened that all patients with clinically stable mild to moderate chronic heart failure (NYHA class II or III), no contraindications to beta-blocker use, and an LVEF less than 40% should be treated with beta-blockers. Based on the results of recent clinical trials on heart failure, beta-blocker therapy should be initiated at a low dose and slowly tirtrated upward as tolerated. A patient's heart failure should be stable for at least 2 weeks before the dose is adjusted upward. Slow titration facilitates maximal tolerability. In primary care practice, physicians should apply titration strategies and target dosed that have been demonstrated to reduce morbidity and mortality in clinical trials. Although worsening heart failure or other adverse events occur in a minority of patients who take beta-blockers, these effects can be managed by adjusting the dose of ACE inhibitor or diuretic, or both, or by temporarily withholding the beta-clocker. Currently, professional treatment guidelines recommend beta-blocker therapy in combination with ACE inhibitors an diuretics as the standard of care in the treatment of heart failure.