Selection of Antihypertensive Drug

BP ClassificationSystolic BP, mm Hg Diastolic BP, mm Hg Normal<120and< 80 Pre hypertension120 – 139or80 – 89 Stage 1 hypertension 140 – 159or90 – 99 Stage 2 hypertension ≥ 160or≥ 100 Hypertension classification

Blood Pressure (mm Hg) Other risk and disease history Stage 1Stage 2 Stage 3 (severe hypertension) SBP or DBP SBP or DBP SBP ≥ 180 or DBP ≥ 110 I No other risk factors Low riskMedium riskHigh risk II1-2 risk factorsMedium risk Very high risk III 3 or more risk factors or TOD or diabetes High risk Very high risk IVACCVery high risk Risk Stratification

Compelling Indication DiureticBBACEIARBCCBALD ANT Heart failure●●●●● Postmyocardi al infarction ●●● High coronary disease risk ●●●● Diabetes●●●●● Chronic kidney disease ●● Recurrent stroke prevention ●● Clinical trial and guideline basis for compelling indications for individual drug classes

Low risk -3 months Medium risk-2 – 3 months High & very high risk -immediate -Diuretics e.g.:- Hydrochlorothiazide 12.5 – 50 mg od

-  - blockers eg:- Atenolol 25 – 100 mg od propranolol long acting 60 – 180 mg od

Calcium channel blockers: Amlodipine 2.5 – 10 mg od Diltiazem XR – 180 – 420 mg od Verapamil long acting 120 – 480 mg od –bd

ACE Inhibitors: Enalapril mg od – bd Ramipril 2.5 – 20mg od

ARBs: Losartan – 25 – 100 mg od – bd

When to add 2 nd drug? -Single drug fails to active BP goal (BP is 20 / 10 mm Hg above goal) -Most stage 2 hypertension Thiazide – type diuretic + ACE, ARB, BB, CCB 1.Enalapril 5 mg + Hydrochlorothiazide 12.5 mg. 2.Losartan 50mg + Hydrochlorothiazide 12.5 mg. 3.Propranolol LA + Hydrochlorothiazide 40 / 25 mg. 4.Amlodipine + Hydrochlorothiazide 5/12.5 mg.

When to add 3 rd drug? What to add? ACE + CCB + Diuretic Enalapril 5 + Amlodipine 5 + Hydrochlorothiazide 12.5 mg BB + CCB + Diuretic Atenolol 50 + Amlodipine 5+ Hydrochlorothiazide12.5mg

Resistant : Add either  - blocker prazosin 2 – 20mg bd –tds or Doxazosin 1 – 16 mg od Spironolactone – 25 mg Other diuretic – Metolazone 2.5 mg – indapamide 1.25 – 2.5 mg

- Acute myocardial ischemia  Nitroglycerin –5 to 10 µg / min as IV infusion   - blockers –ESMOLOL 250 to 500 µg / kg / min for I minute, then 50 to 100 µg / kg for 4 minutes  ACEI (if available) – ENALAPRILAT 1.25 to 5 mg q6 hour IV -CHF with pulmonary edema  Nitroglycerin –5 to10 µg / min as IV infusion  Frusemide  Morphine

- Acute aortic dissection  Nitroprusside IV plus  - blockers esmolol 1. Dose is 5 to 10 µg / min as IV infusion 2. Dose is 250 to 500 µg / kg / min for I minute, then 50 to 100 µg / kg for 4 minutes.  Alternative – Trimethaphan plus  - blocker - Cerebral vascular accident:  Nitroprusside - 5 to10 µg / min as IV infusion  Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion  Nimodipine

- Pheocheromocytoma  Phentolamine 5-15 mg IV  Nitroprusside –5 to 10µg / min as IV infusion  Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion - Hypertensive encephalopathy  Nitroprusside –5 to 10µg / min as IV infusion  Trimethaphan   - blockers to 500µg / kg / min for I minute, then 50 to 100µg / kg for 4 maintained

Hypertensive encephalopathy  Hydralazine mg IV / IM  Labetalol – 20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion  Magnesium IV

ClassDrug (Trade Name)Usual Dose Range in mg/Day Usual Daily mg/Day Frequency* Thiazide diuretics chlorothiazide chlorthalidone hydrochlorothiazide polythiazide indapamide metolazone 125– – –50 2–4 1.25– – –5 1–2 1 Loop diuretics bumetanide furosemide torsemide 0.5–2 20–80 2.5– Potassium- sparing diuretics amiloride triamterene 5–10 50–100 1–2 Aldosterone receptor blockers eplerenone Spironolactone 50–100 25–

ClassDrug (Trade Name)Usual Dose Range in mg/Day Usual Daily mg/Day Frequency* BBsAtenolol Propranolol propranolol long-acting 25– Combined alpha- and BBs Carvedilol labetalol 12.5–50 200– ACEIsenalapril ramipril Angiotensin II antagonists losartan CCBs— nondihydropyr idines diltiazem extended release verapamil immediate release verapamil long acting Verapamil

ClassDrug (Trade Name)Usual Dose Range in mg/Day Usual Daily mg/Day Frequency* CCBs- dihydropyridi nes amlodipine nifedipine long-acting Alpha-1 blockers doxazosin prazosin terazosin Central alpha- 2 agonists and other centrally acting drugs clonidine clonidine patch methyldopa reserpine guanfacine wkly 2 1 Direct vasodilators hydralazine minoxidil