SELECTION OF ANTIHYPERTENSIVE DRUGS IN INDIVIDUAL PATIENTS

Choice of an antihypertensive drug should be driven by likely benefit in an individual patient,

taking into account concomitant diseases such as diabetes mellitus, problematic adverse effects
of
specific drugs, and cost.
Consensus guidelines ((www.nhlbi.nih.gov/guidelines/hypertension) recommend diuretics as
preferred initial therapy for most patients with uncomplicated stage 1 hypertension who are
unresponsive
to nonpharmacological measures. Patients are also commonly treated with other drugs:
b receptor antagonists, ACE inhibitors/AT 1 receptor antagonists, and Ca2+ channel blockers.
Patients with uncomplicated stage 2 hypertension will likely require the early introduction of a
diuretic and another drug from a different class. Subsequently, doses can be titrated upward and
additional drugs added in order to achieve goals (blood pressure 140/90 mm Hg in
uncomplicated
patients). Some of patients may require four different drugs to reach their goal.
Some patients with hypertension have compelling indications for specific drugs on account of
other underlying serious cardiovascular disease (heart failure, postmyocardial infarction, or with
high risk for coronary artery disease), chronic kidney disease, or diabetes. For example, a
hypertensive
patient with congestive heart failure ideally should be treated with a diuretic, b receptor
antagonist, ACE inhibitor/AT 1 receptor antagonist, and spironolactone because of the benefit of
these drugs in congestive heart failure, even in the absence of hypertension. Similarly, ACE
inhibitors/AT1 receptor antagonists should be first-line drugs in the treatment of diabetics with
hypertension in view of their well-established benefits in diabetic nephropathy.
Other patients may have less serious underlying diseases that could influence choice of
antihypertensive
drugs. For example, a hypertensive patient with symptomatic benign prostatic hyperplasia
might benefit from having an a1 receptor antagonist as part of this therapeutic program, since
a1 antagonists are efficacious in both diseases. Similarly, a patient with recurrent migraine
attacks
might particularly benefit from use of a b receptor antagonist since a number of drugs in this
class
are efficacious in preventing migraine attacks.
Patients with isolated systolic hypertension (systolic blood pressure 160 mm Hg and diastolic
blood pressure 90 mm Hg) benefit particularly from diuretics and also from Ca 2+ channel
blockers.
Different considerations are needed for patients in immediately life-threatening settings due to
hypertension. Clinical judgment favors rapidly lowering blood pressure in patients with
lifethreatening
complications of hypertension, such as patients with hypertensive encephalopathy or
pulmonary edema due to severe hypertension. Rapid reduction in blood pressure has
considerable
risks for the patients; if blood pressure is decreased too quickly or extensively, cerebral blood
flow
may diminish due to adaptations in the cerebral circulation that protect the brain from the
sequelae
of very high blood pressures. The temptation to aggressively treat patients merely on the basis
of
increased blood pressure should be resisted and therapy should encompass how well the
patients
major organs are reacting to the very high blood pressures.