High Blood Pressure / Hypertension

Which drugs to use

By Cardiologist on August 13th, 2011

Which drugs to use in subgroups of hypertensive patients

Although clinical trials done specifically in hypertensive patients were unable to allow us to make broad evidence-based recommendations, other trials were quite helpful in delineating special subgroups of hypertensive patients for whom certain classes of agents would be preferred or even the drugs of choices.

Table Trials Addressing Which Drugs to Use in Subgroups of Hypertensive Patients

The data on which such recommendations are based came from clinical trials that were not planned to be studies of drug treatment in hypertensive patients but came rather from studies done in subgroups of patients with complications or risk factors commonly encountered in hypertensive patients and in which the drugs employed are also used to reduce blood pressure (Table Trials Addressing Which Drugs to Use in Subgroups of Hypertensive Patients). For example, angiotensin-converting enzyme inhibitors should be part of the regimen for hypertensive type 1 diabetics with proteinuria. β-blockers should be given after myocardial infarction. Diuretics and angiotensin-converting enzyme inhibitors and possibly β-blockers should be given to hypertensive patients with heart failure. Hypertensive patients who survive an anterior wall myocardial infarction and have a reduced ejection fraction should have an angiotensin-converting enzyme inhibitor included in the regimen. These recommendations can be made with assurance because clinical trials (the Captopril Diabetes Study, β-Blocker Heart Attack Trial, Survival and Ventricular Enlargement, Studies of Left Ventricular Dysfunction, and many others) demonstrated that those agents reduced events. These studies were the basis of the “compelling indications” recommendations by JNC VI to use these classes of drugs in those subgroups of hypertension.

There are also many other clinical situations in which the choice of antihypertensive therapy should be selected or avoided because of a comorbid condition or risk factor present in a particular patient (Table Considerations for Individual Antihypertensive Drug Therapy). In these situations, there either has not been or more likely never will be a clinical trial that provides the level of evidence some clinicians require. Any reasonable clinician, however, would likely treat such an individual according to the suggestions made by JNC VI. The presence of benign prostatic hypertrophy in a hypertensive patient who needs drug therapy, e.g., would be a good reason to include an a-blocker in the regimen, because this class of drugs improves symptoms in men with this problem. Even if diuretics are the drugs of choice in older persons, elderly hypertensive patients with gout should almost surely be treated with some other class of agents.

Table Considerations for Individual Antihypertensive Drug Therapy

Sometimes comorbid conditions may influence the choice of initial therapy, based not on the likelihood of improvement in symptoms or worsening of a comorbid condition, but because of other clinical factors. Diuretics, e.g., will increase bone mass and may prevent osteoporotic fractures. Thus, diuretics would be a good choice in a hypertensive patient who has or was at risk of having osteoporosis.

The issue in two particularly important subgroups, the elderly and type 2 diabetes, is less clear. Although β-blockers and diuretics may have adverse metabolic effects (raising triglycerides, lowering high-density lipoprotein cholesterol and worsening glucose tolerance), the SHEP study demonstrated clear benefit in the subgroup with type 2 diabetes. In Syst-EUR, in which the regimen began with a dihydro-pyridine followed by an angiotensin-converting enzyme inhibitor and a diuretic, the subgroup with type 2 diabetes also did particularly well. Perhaps the key point is that both of these studies showthe clear benefit of lowering BPinhypertensive patients with a high absolute risk. In 1994, the National High Blood Pressure Working Group on Diabetes included angiotensin-converting enzyme inhibitors, a-blockers, a/β-blockers, calcium antagonists, and diuretics all as appropriate choices for initial therapy in diabetes. Now the group would probably add angiotensin receptor blockers to that list.

In the elderly the choice is also complex. As discussed, diuretics are clearly better than β-blockers but data from Syst-EUR clearly showed the benefits of treatment with a moderately long-acting dihydro-pyridine as well. Here, too, in this other high-risk group, effective lowering of blood pressure is perhaps more important than exactly how it is done.

Table Some Clinical Trials Currently in Progress

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