Drug Therapy of Hypertension

By Wilbert S. Aronow, MD, FACC and Julio A. Panza, MD, FACC*

Although lifestyle measures are an essential part of the treatment of hypertension, antihypertensive drugs are required in the vast majority of patients in order to achieve their blood pressure goals.1-4 This article reviews the most current recommendations for pharmacotherapy in essential hypertension, with a focus on the suggested drugs for the most common associated conditions.

According to the most recent guideline, patients with clinical cardiovascular disease (coronary heart disease, heart failure, and stroke) should have their blood pressure reduced to less than 130/80 mm Hg for secondary prevention of recurrent events.4 Similarly, blood pressure should be lowered below 130/80 mm Hg for primary prevention of cardiovascular disease in persons with an estimated 10-year risk of atherosclerotic cardiovascular disease ≥10%.4,5 In contrast, blood pressure should be lowered below 140/90 mm Hg for primary prevention when the estimated 10-year risk of atherosclerotic cardiovascular disease is <10%.4,5 Antihypertensive drug therapy should be initiated with 2 first-line drugs from different classes either as separate drugs or in a fixed-dose combination in persons with a blood pressure of 140/90 mm Hg and higher or with a blood pressure 20/10 mm and higher Hg above their blood pressure target.4

The first antihypertensive drug used to treat white and other non-black adults younger than 60 years of age with primary hypertension, should be an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).4 The second drug used should be a thiazide diuretic (preferably chlorthalidone) or a calcium channel blocker (CCB). If a third antihypertensive drug is needed to control the hypertension, an ACE inhibitor or ARB plus a thiazide diuretic plus a CCB should be used.4 The first antihypertensive drug used to treat white and other non-black adults aged 60 years of age and older with primary hypertension should be a thiazide diuretic (preferably chlorthalidone) or a CCB.4 If a third antihypertensive drug is needed to control the hypertension, a thiazide diuretic plus a CCB plus an ACE inhibitor or ARB should be used.4 The first antihypertensive drug used to treat black adults with primary hypertension should be a thiazide diuretic (preferably chlorthalidone) or a CCB.4 If a third antihypertensive drug is needed to control the hypertension, a thiazide diuretic plus a CCB plus an ACE inhibitor or ARB should be used.4

Persons with hypertension and stable coronary heart disease should be treated with a beta blocker plus an ACE inhibitor or ARB.1,3,4,6-8 If a third antihypertensive drug is needed to control the hypertension, a beta blocker plus an ACE inhibitor or ARB plus a thiazide diuretic or a CCB should be used.4 If a fourth antihypertensive drug is needed to adequately control hypertension, an aldosterone antagonist should be given.4 In persons with stable ischemic heart disease who have angina pectoris despite beta blocker therapy and persistent uncontrolled hypertension, a dihydropyridine CCB should be added.1,3,4,7 The beta blockers that should be used for treatment of hypertension in patients with coronary heart disease include carvedilol, metoprolol tartrate, metoprolol succinate, bisoprolol, nadolol, propranolol, and timolol.4 Atenolol should not be used.1,3.4,8,9 The nondihydropyridine CCBs verapamil and diltiazem are contraindicated if left ventricular systolic dysfunction is present.1,3,4 Carvedilol, metoprolol succinate, or bisoprolol are the beta blockers to be used if left ventricular systolic dysfunction is present.1,3,4,7, 8

If patients with an acute coronary syndrome have hypertension after treatment with a beta blocker plus an ACE inhibitor or ARB, a long-acting dihydropyridine CCB such as amlodipine or felodipine should be added.1,3 Aldosterone antagonists should be given to patients treated with beta blockers plus ACE inhibitors or ARBs after myocardial infarction with left ventricular systolic dysfunction and heart failure or diabetes mellitus if their serum potassium is less than 5.0 meq/L and if their serum creatinine is ≤2.5 mg/dL in men and ≤ 2.0 mg/dL in women.1,3,4,10

Patients with hypertension and heart failure with a decreased left ventricular ejection fraction (HFrEF) should be treated with carvedilol, metoprolol succinate, or bisoprolol plus an ACE inhibitor or ARB or preferably an angiotensin receptor -neprilysin inhibitor plus a diuretic and if necessary with an aldosterone antagonist.1,3,4,10,11 Nondihydropyridine CCBs are contraindicated in patients with HFrEF).1,3,4,11

Patients with hypertension and heart failure with a preserved left ventricular ejection fraction should have their volume overload treated with diuretics, their comorbidities treated, and their hypertension treated with a beta blocker plus an ACE inhibitor or ARB plus an aldosterone antagonist.3,4,11-13

Hypertensive adults with chronic kidney disease stage 3 or higher or stage 1 or 2 chronic kidney disease with albuminuria ≥300 mg per day should be given an ACE inhibitor to slow progression of their chronic kidney disease.4, 14 If an ACE inhibitor is not tolerated, an ARB should be used.4 Patients with stage 1 or 2 chronic kidney disease without albuminuria may be given usual first-line antihypertensive drugs.4 If 3 antihypertensive drugs are necessary, an ACE inhibitor or ARB plus a thiazide diuretic plus a CCB4 are the preferred choices. After kidney transplantation, hypertension should be treated with a CCB to improve glomerular filtration rate and kidney survival.4,15

Hypertensive patients with a prior stroke or transient ischemic attack should be treated with a thiazide diuretic or ACE inhibitor or ARB.4, 16 If a third antihypertensive drug is needed , they should be receive a thiazide diuretic plus an ACE inhibitor or ARB plus a CCB.4

Thiazide diuretics, ACE inhibitors, ARBs, and CCBs may be used as initial treatment in hypertensive diabetics.4, 17-19 ACE inhibitors or ARBs should be given to hypertensive diabetics with persistent albuminuria.4,20

Beta blockers are the preferred antihypertensive drugs in hypertensive patients with a thoracic aortic aneurysm.4,21 Beta blockers also improve survival in patients with type A and with type B acute and chronic thoracic aortic dissection.4,22,23 Pregnant women with hypertension should be treated with methyldopa, nifedipine, and/or labetalol.4,24

 

Wilbert S. Aronow, MD, FACC and Julio A. Panza, MD, FACC
Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA

 

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