A simple stepped regimen in keeping with the 1999 British Hypertension Society guidelines30 is the AB/CD schema illustrated in Figure 23.2:33
1. Depending on the patient's age (see above) use either a p Blocker or thiazide Diuretic as firstline therapy, unless there is a compelling reason to avoid these (e.g. asthma and gout, respectively). If the first drug is effective but not tolerated, switch to the other member of the pair: i.e. ACE inhibitor (or AIIRA) instead of P-blocker, Calcium blocker instead of diuretic.
2. If the blood pressure is not controlled in
4 weeks by the first-line drug then switch to a
33 Dickerson J E C et al 1999 Lancet 353: 2008-2013.
drug from the other pair, e.g. a thiazide Diuretic should be replaced by a P-Blocker, and vice versa.
3. If the blood pressure is still not controlled, a second agent should be added, using the opposite pair to the first drug e.g. if the patient is on an ACE inhibitor add a Calcium channel blocker or thiazide Diuretic (A+C or A+D), since both vasodilatation or diuresis will stimulate the renin-angiotensin system and turns nonrenin-dependent hypertension into renin-dependent hypertension). The combination B+D is associated with increased risk of diabetes and should be avoided in at-risk patients (obesity, family history). The combinations A+B or C+D usually produce a less than additive effect on blood pressure, but should be tried in patients still uncontrolled on more standard combinations.
4. If blood pressure control is still inadequate on dual therapy A+C+D is the ideal triple regimen.
4a. If additional therapy is required, a-blockade is effective at this stage by blocking the vasoconstrictor component of the baroreflex response to some of the other drugs. A very
AB/CD Rule for optimisation of antihypertensive treatment
(AB/CD =ACEi, Beta-b I ocker/Ca++-blocker, Diuretic)
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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...