Beta-blockers continue to surprise us.

Beta-blockers are well established in the treatment of coronary heart disease and hypertension but until fairly recent times many doctors would have considered the prescription of beta-blockers to patients with heart failure as contraindicated and to patients with type II diabetes as relatively contraindicated. However, we now know that (a) beta-blockers can significantly reduce mortality in patients with stable heart failure and that this benefit for both ischaemic and non-ischaemic failure is due to beta1 selective blockade ; (b) the recent publications of the classic U.K. Prospective Diabetes Study Group (UKPDS) have changed the way we think about beta-blockers and the treatment of type II diabetics with hypertension. Other recent surprising results (Table 1) are (i) the SOLVD heart failure study, which indicated that, in contrast to enalapril, beta-blockers were renoprotective (in both the placebo and ACE-inhibitor groups) (Table 2); (ii) perhaps less surprising, but of considerable importance, is the study showing that bisoprolol significantly reduced perioperative mortality and non-fatal attacks in non-cardiac vascular surgical patients, and (iii) in elderly hypertensives atenolol-based treatment, in contrast to diureticbased treatment, did not prevent heart attacks. There has been a long held bias for the use of ACE inhibitors and against the use of beta-blockers in diabetes. This is possibly understandable when one considers a typical hypertensive type II diabetic who might be obese and insulin resistant with a high fasting blood triglyceride concentration, high fasting blood sugar and glycated haemoglobin (HbA1c) levels, a low HDL cholesterol concentration and might be on insulin therapy. Prior to the UKPDS publications the choice of antihypertensive agent, between an ACE inhibitor and a beta-blocker, to treat such a patient would not have been difficult. A negative beta-blocker image in diabetes