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Resistant HTV intolerance

4: Add/substitute alpha blocker

5: Re-consider 2 causes! trial of spironolactone

Fig. 23.2 Scheme for escalation of anti-hypertensive therapy. A: ACE inhibitor; B: P-adrenoceptor blocker; C: calcium channel blocker; D: diuretic (see text). (From: Dickerson et al. 1999 Lancet 353:2008-2011.)

small number of patients may need reversion to an older class of drug such as minoxidil (provided that a loop diuretic and (i-blocker can also be given to block the severe fluid retention and tachycardia) or methyldopa. 5. Patients whose blood pressure remains substantially above target on triple therapy are likely to have aldosterone-sensitive hypertension that responds well to spironolactone. A particularly effective combination is spironolactone with a second generation AIIRA (e.g. irbesartan or candesartan).

Treatment and severity

A single drug may adequately treat mild hypertension. The treatment target blood pressures of <140/<85 suggested by the British Hypertension Society30 will, however, increase the proportion of patients needing two or more drugs. The vast majority of patients with more severe hypertension should be treated by the stepped regimen (above); only rarely are there indications that a more rapid reduction in blood pressure is necessary. This is important so that the efficacy and tolerability of individual drugs can be assessed in each patient.

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Reducing Blood Pressure Naturally

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