Nationwide surveillance for S-Metoprolol treatment effect on blood pressure control against sympathetic overdrive in Indian patients with hypertension (PROTECT)


  • D. Ramesh Department of Cardiology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, Karnataka, India
  • Parminder Singh Kumar Consultant Cardiologist, Ayaan Cardiac Center, Nanded, Maharashtra, India
  • Priya Palimkar Interventional Cardiologist, Jehangir Hospital, Pune, Maharashtra, India
  • Krishna Dhoot Cardiologist, Hrudaysparsh Heart Care Centre, Pune, Maharashtra, India
  • Dhammdeep C. Dabhade Senior Medical Advisor, Medical Services, Emcure Pharmaceuticals Limited, Pune, Maharashtra, India
  • Sanket Newale Deputy General Manager, Medical Services, Emcure Pharmaceuticals Limited, Pune, Maharashtra, India



Hypertension, Sympathetic overdrive, Beta-blocker, S-Metoprolol, PROTECT


Background: Patients with hypertension in India been reported with high heart rate owing to sympathetic overdrive (SO). Beta-blockers provides several positive effects to reduce SO in patients with hypertension. The aim of present survey study was to understand current real-world prevalence of SO in Indian patients with hypertension and usage of beta-blocker therapy in them.

Methods: A cross sectional, observational, questionnaire-based survey conducted across India between June 2020 to October 2020. A specially designed validated questionnaire was shared with 157 registered health care practitioners (HCP), their anonymous inputs were captured and analysed in qualitative manner. Categorical data was summarized by number (n) and percentage (%).  

Results: Total 157 HCP participated and completed the survey. Around 53% of HCP observed that patients with average heart rate above 75 beats/min were associated with negative prognosis. Around 43% of HCP reported that raised heart rate is associated with advanced age and increased body mass index (BMI). Two-third of HCP reported that tachycardia is associated with stage-2 hypertension and marked by restlessness and anxiety which is suggestive of SO. Over 70% HCP agreed that the HR below 75 beats/min is associated with good prognosis. Around 89% HCP reported beta-blockers as the drug of choice in patients with augmented SO. S-Metoprolol was reported to be the most preferred beta-blocker agent and was recommended by 76% HCP in patients with hypertension and coexisting SO.

Conclusions: SO been reported prevalent condition in Indian patients with hypertension which likely worsens the prognosis in these patients. Beta-blockers reported to be the preferred choice of anti-hypertensive and S-Metoprolol seem to be the most preferred agent amongst the available beta-blockers against SO in patients with hypertension in India.


Palatini P. Resting Heart Rate as a Cardiovascular Risk Factor in Hypertensive Patients: An Update. Am J Hypertens. 2021;34(4):307-17.

Cooney MT, Vartiainen E, Laatikainen T, Juolevi A, Dudina A, Graham IM. Elevated resting heart rate is an independent risk factor for cardiovascular disease in healthy men and women. Am Heart J. 2010;159(4):612-9.

Palatini P. Elevated heart rate: a "new" cardiovascular risk factor? Prog Cardiovasc Dis. 2009;52(1):1-5.

Grassi G. Sympathomodulatory Effects of Antihypertensive Drug Treatment. Am J Hypertens. 2016;29(6):665-75.

Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31(7):1281-357.

Houle SK, Padwal R, Poirier L, Tsuyuki RT. The 2015 Canadian Hypertension Education Program (CHEP) guidelines for pharmacists: An update. Can Pharm J (Ott). 2015;148(4):180-6.

Ibrahim MM. The Egyptian hypertension society: Egyptian hypertension guidelines. Egypt Heart J. 2014; 66(2):79-132

NICE. Hypertension in adults: diagnosis and management. London: National Institute for Health and Care Excellence; 2019.

Boynton PM, Greenhalgh T. Selecting, designing, and developing your questionnaire. BMJ. 2004;328(7451):1312-5.

Mancia G, Grassi G, Giannattasio C, Seravalle G. Sympathetic activation in the pathogenesis of hypertension and progression of organ damage. Hypertension. 1999;34(4):724-8.

Kaul U, Wander GS, Sinha N, Mohan JC, Kumar S, Dani S, et al. Self-blood pressure measurement as compared to office blood pressure measurement in a large Indian population; the India Heart Study. J Hypertens. 2020;38(7):1262-70.

SPRINT Research Group, Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015;373(22):2103-16.

Mann SJ. Redefining beta-blocker use in hypertension: selecting the right beta-blocker and the right patient. J Am Soc Hypertens. 2017;11(1):54-65.

Padmanabhan TN, Dani S, Chopra VK, Guha S, Vasnawala H, Ammar R. Prevalence of sympathetic overactivity in hypertensive patients - a pan India, non-interventional, cross sectional study. Indian Heart J. 2014;66(6):686-90.

Dasbiswas A, Shinde S, Dasbiswas D. S-metoprolol: the 2008 clinical review. J Indian Med Assoc. 2008;106(4):259-62.

Mohan JC, Shah SN, Chinchansurkar S, Dey A, Jain R. Rediscovering Chirality - Role of S-Metoprolol in Cardiovascular Disease Management. J Assoc Physicians India. 2017;65(6):74-9.






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