In reality they are only four groups of antihypertensive agents available. In clinical practice patients who cannot tolerate one or two of the four types of agents are freq¬uently encountered and many patients require two agents to maintain adequate blood pressure control.
The following statement is modified from the sixth edition of Cardiac Drug Therapy:
This situation will change only if pharmaceutical companies and experts who formulate hypertension therapeutic guidelines will admit that after more than 50 years of research and numerous randomized clinical trials we only have four antihypertensive agents. Recognition of the truth should promote more intensive research to discover new groups of agents to add to our armamentarium.
The organizers of randomized trials must provide sound methodology, which has been lacking in many trials. For example, the well-known beta-blocker, atenolol, has been compared with other agents in several trials. However, the nonlipid-soluble atenolol is not as cardioprotective as carvedilol, metoprolol, bisoprolol, or propranolol, which are the only beta-blockers proven in clinical trials to be cardioprotective. Beta-blockers have subtle and important differences that appear to be unrecognized by experts who organize clinical trials of hypertension.

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