THE debate on the use of atenolol as the sole treatment for hypertension, and its role as the reference drug by which other hypotensive drugs (those that lower blood pressure) are measured, is useful.

It may well be that innate medical conservatism and inertia have encouraged doctors to continue to prescribe atenolol as their first choice when selecting a beta blocker for a patient and that there are now others that should have superseded it.

It is hoped that what this debate will have achieved is to have drawn attention to the need in many cases of high blood pressure to use more than one type of drug if the blood pressure is to be lowered to safe levels. Furthermore it will help to emphasise the need to regard the treatment of blood pressure as being a matter of bespoke tailoring rather than ready made off-the-peg suit buying.

As The Black Watch moves into action in Iraq, it wouldn’t go into battle unsupported by an armoured squadron from the Queen’s Dragoon Guards. Other support forces are in reserve. It is frequently as much poor medicine to try and rely on only one drug as it would be to use unsupported infantry.

A battle plan to defeat high blood pressure, which kills and cripples thousands a year from strokes and heart attacks, has been drawn up the British Hypertensive Society. Younger (under-55) non-black patients should be started on an ACE inhibitor or an angiotension receptor blocker, or a beta blocker (but not necessarily atenolol). Older patients, or those who are black and of any age, should be started on a calcium channel blocker or a diuretic. If this doesn’t bring the blood pressure down to acceptable limits, two drugs from different groups should be used. If the blood pressure is still raised, three different drugs are tried. In the really resistant cases, four may be necessary.

The paradox, whereby some hypotensive drugs will lower blood pressure but not apparently contribute to saving life, has been noted for some years. It has been suggested that this could be related to the tendency of some beta blockers to increase blood cholesterol levels. Another problem is that beta blockers like atenolol are not as effective as some other types of beta blocker at reducing the incidence of the potentially fatal ventricular fibrillation (a disastrously irregular heart beat).

The advantage of atenolol that persuaded doctors to prescribe it was that as it didn’t cross the blood brain barrier it didn’t cause tiredness and sedation. Unfortunately this very advantage may have only been obtained at the cost of efficiency in controlling the potentially fatal ventricular fibrillation. This is dependent on high levels of appropriate beta blockers in the brain. I have taken atenolol for years, but now I shall have a word with my doctor about a possible change.

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