Antihypertensive Drugs

Blood pressure lowering therapy should be considered in individuals with repeated measures of systolic blood pressure >140mmHg and/ or diastolic blood pressure >90mmHg. Guidelines recommend that the overall cardiovascular risk should be considered.1 Treatment directed at lowering blood pressure should include lifestyle change encompassing smoking cessation, moderation of alcohol consumption, weight reduction, physical exercise, reduction of high salt intake and other dietary changes. When these measures fail, pharmacological treatment is indicated.

A number of large clinical trials have investigated differences in the efficiency of older versus newer antihypertensive drug strategies. In general, no clear-cut differences are detectable between the various classes of antihypertensive drugs, although this statement is a matter of ongoing dispute. In initiating drug treatment, therapy should always be started gently, and target blood pressure will not generally be achieved within the first months. An important modern principle of drug treatment is to attempt combination therapy early on. Many experts recommend a low dose of a single drug as the primary approach, and if blood pressure control is not achieved, to add a low dose of a different agent, rather than increasing the dose of the first compound. The reason for this strategy is to diminish the possibility of eliciting adverse effects of the drugs. It is essential to keep in mind that antihypertensive therapy must remain operational for many years, even decades, in most patients. Classes of antihypertensive drugs that are currently available are shown in Table 53-1.

In general contemporary treatment allows for almost all combinations of the various drug classes. Combinations that are particularly effective include:

- diuretics and beta-blockers

- diuretics and ACE inhibitors

- diuretics and angiotensin receptor blockers

- calcium antagonists and beta-blockers

- calcium antagonists and ACE inhibitors

- calcium antagonists and angiotensin receptor blockers

- calcium antagonists and diuretics

- alpha-blockers and beta-blockers

Nevertheless, in the presence of certain conditions, the so-called "compelling indications," the

Table 53-1. Classes of antihypertensive drugs that are currently available

Diuretics Beta-blockers Alpha-1-blockers ACE inhibitors

Angiotensin receptor blockers

Calcium antagonists

Centrally active receptor-antagonists use of specific antihypertensive classes is mandated, as shown in Table 53-2.

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