Monotherapy for hypertension
Only a minority of patients with hypertension reach their BP targets using only a single drug, so most patients require multiple drugs. Several influential hypertension treatment guidelines have converged on four drug classes as preferred initial therapy, with some exceptions for patients with certain characteristics. In order of their historical introduction, they are:
- 1. Thiazide or thiazide-like diuretics
- 2. Calcium channel antagonists
- 3. Angiotensin-converting enzyme (ACE) inhibitors
- 4. Angiotensin receptor blockers
Most guideline committees agree that if a patient has a condition for which a specific type of antihypertensive drug improves prognosis, that medication can be used as initial therapy to lower BP. A hypertensive survivor of a recent myocardial infarction, for example, would benefit from a β-blocker to reduce the risk of death or recurrent infarction, so a β-blocker would be appropriate initial antihypertensive therapy in such a case. All guideline committees recognize the existence and importance of contraindications (including allergies), even for drugs that might otherwise be first-line choices. Recent guidelines have become more concordant with one another with respect to first-line choices of antihypertensive medications.
Effects of Different Classes of Antihypertensive Agents on Surrogate Markers of Cardiovascular DiseaseFrom Johnson, R. J., & Feehally, J. (2003). Comprehensive clinical nephrology (2 nd ed.). Philadelphia: Mosby.
CENTRAL α-AGONISTS | α-BLOCKERS | α-, β-BLOCKER | VASODILATOR | β-BLOCKERS | ACE INHIBITORS | ATRAS | CCBS | DIURETICS | |
|---|---|---|---|---|---|---|---|---|---|
| Metabolic | |||||||||
| LDL cholesterol | → | → | → | → | → a ↑ | → | → | → | →↑ |
| HDL cholesterol | → | ↑ | → | → | →↓ | → | → | → | → |
| Insulin resistance | → | ↓ | →↓ | →↑ | →↑ | ↓ | ↓ | → | →↑ |
| Glucose control | → | → | → | → | →↓ | →↑ | → | → | →↑ |
| Cardiovascular | |||||||||
| Left ventricular hypertrophy | ↓ | ↓ | ↓ | →↑ | ↓ | ↓ | ↓ | ↓ | →↑ |
| Renal | |||||||||
| Microalbuminuria | → | → | →↓ | →↑ | →↑ | ↓↓ | ↓↓ | b → | →↑ |
ACE, Angiotensin-converting enzyme; ATRAs, angiotensin II receptor antagonists; CCBs, calcium channel blockers; LDL, low-density lipoprotein; HDL, high-density lipoprotein; →, no effect; ↑, increase; ↓, decrease.
a Only β-blockers with intrinsic sympathomimetic activity.
b Only nonhydropyridine calcium channel blockers (verapamil, diltiazem).
