Hypertension Management Part 3 Pharmacologic Treatment
Complications of hypertension can be effectively reduced by lowering blood pressure (BP) with agents from several classes of drugs, or combinations. Most effective, according to clinical trial results, are angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), and thiazide-type diuretics.
In most clinical trials, thiazide-type diuretics have been “virtually unsurpassed” in preventing cardiovascular complications of hypertension. These relatively inexpensive agents are recommended as initial therapy for most patients with uncomplicated hypertension; they also enhance the efficacy of multidrug regimens. Thiazide-type diuretics are considered underused.
In patients whose baseline blood pressure (BP) exceeds 20/10 mm Hg above goal, the health care professional should consider initiating therapy with two agents, typically including a thiazide-type diuretic. To achieve the established target BPs, most clinicians will have to prescribe two or more medications for their hypertensive patients. In patients with “compelling indications” (TABLE 2), antihypertensive agents other than thiazide-type diuretics may be a more appropriate initial therapy.
| Table 2 Compelling Indications for Individual Drug Classes Recommended Drugs | ||||||
| Compelling indication• | Diuretic | BB | ACEI | ARB | CCB | Aldo ANT |
| Heart failure | • | • | • | • | • | |
| Postmyocardial infarction | • | • | • | |||
| High coronary disease risk | • | • | • | • | ||
| Diabetes | • | • | • | • | • | |
| Chronic kidney disease | • | • | ||||
| Recurrent stroke prevention | • | • | ||||
| BB, b-blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; Aldo ANT, aldosterone antagonist. * These compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines, with BP management parallel with that of the indication. |
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Individualizing Treatment
When adequate doses of a single drug do not suffice, a second agent from a different class should be added. Caution is required in patients at risk for orthostatic hypotension (eg, elderly patients or those with diabetes or autonomic dysfunction). Medication costs may be reduced by prescribing generic or combination agents.
In addition to the compelling indications listed in table 2 and the desired blood pressure (BP) targets, the clinician and pharmacist must consider tolerability and other medications the patient is taking. Consultation with a specialist may be necessary for patients with high-risk conditions.
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