1. Selection of Antihypertensive Drug

2. Selection of Antihypertensive Drug
Alpha Blocker
AT1Antagonist
 - agonists
ACE Inhibitor
Ganglionic blockers
Dr. Rx
Rational
Drug of choice
Beta Blocker
Vasodilators
Ca++ Antagonist
Diuretic

3. Selection of Antihypertensive Drug
Level of blood pressure +
Presence of other risk factors for CVD
& target organ damage
Coexisting diseases 1 2 3
Antihypertensive Therapy

4. Pharmacotherapy of Hypertension

5. Pharmacotherapy of Hypertension
Target organ damage/clinical CVD
LVH - Heart failure - Angina - Prior MI
or revascularization
Stroke or TIA
Nephropathy
Retinopathy
Peripheral vascular disease

6. Blood Pressure Classification
JNC 7
SBP DBP
mm Hg mmHg
Normal
Prehypertensive
Stage 1 Hypertension
Stage 2 Hypertension
< and <80 or or
> or > 100

7. Goal Blood Pressure JNC 7 < 140 < 90 < 130 < 80 mm Hg mmHg
SBP DBP
mm Hg mmHg
Most patients
Diabetes
Chronic Renal Disease
< < 90
< < 80

8. Lifestyle Modifications
JNC 7
Lifestyle Modifications
Approximate SBP Reduction
mmHg
5 – 20
8 – 14
2 – 8
4 – 9
2 – 4
Weight reduction
DASH eating plan
Reduced Sodium Intake
Physical activity
Moderation of alcohol
consumption

9. Algorithm for Treatment of Hypertension
JNC 7
Algorithm for Treatment of Hypertension
Lifestyle
Modifications
Not at Goal Blood Pressure
Initial Drug
Choices

10. Algorithm for Treatment of Hypertension
JNC 7
Algorithm for Treatment of Hypertension
Initial Drug
Choices
“Excellent clinical trial outcome data prove
that lowering BP with several classes of drug,
including ACE inhibitors, angiotensin receptors
blockers (ARBs),”beta-blockers”, calcium channel
blockers (CCBs) and thiazide-type diuretics
will reduce the complications of hypertension.”

11. Algorithm for Treatment of Hypertension
JNC 7
Initial Drug
Choices
Without
Compelling
Indication (s)
With
Compelling
Indication (s)

12. Algorithm for Treatment of Hypertension
JNC 7
Initial Drug Choices
Stage 1- Hypertension / mmHg
Without Compelling Indication
Thiazide-like diuretics for most,
ACEI, ARB, BB or CCB
May consider combination

13. Algorithm for Treatment of Hypertension
JNC 7
Initial Drug Choices
Stage 2 - Hypertension >160 / > 100 mmHg
Without Compelling Indication
2-drug combination for most
Usually thiazide-like diuretic plus ACEI,
or ARB, or BB or CCB

14. Algorithm for Treatment of Hypertension
JNC 7
Initial Drug Choices
Without
Compelling Indication (s)
With
Compelling Indication (s)
Not at Goal Blood Pressure
Optimize dosage or add additional
drug until goal BP is achieved. Consider
consultation with HNT specialist

15. Clinical trial and guideline basis for compelling indications for individual drug classes
Diuretic BB
ACEI
ARB
CCB
ALD & ANT
Heart failure ●
Postmyocardial infarction
High coronary disease risk
Diabetes
Chronic kidney disease
Recurrent stroke prevention

16. Class
Drug (Trade Name)
Usual Dose
Range in
mg/Day
Usual Daily
Frequency*
Thiazide diuretics
chlorothiazide
chlorthalidone
hydrochlorothiazide
polythiazide
indapamide
metolazone
125–500
12.5–25
12.5–50
2–4
1.25–2.5
0.5–1.0
2.5–5
1–2 1
Loop
diuretics
bumetanide
furosemide
torsemide
0.5–2
20–80
2.5–10 2
Potassium-sparing diuretics
amiloride
triamterene
5–10
50–100
Aldosterone receptor blockers
eplerenone
Spironolactone
25–50

17. Class
Drug (Trade Name)
Usual Dose
Range in
mg/Day
Usual Daily
Frequency*
BBs
Atenolol
Propranolol
propranolol long-acting
25–100
40-160
60-180 1 2
Combined
alpha- and
Carvedilol
labetalol
12.5–50
200–800
ACEIs
enalapril
ramipril
5-40
2.5-20
1-2
Angiotensin II antagonists
losartan
25-100
CCBs—nondihydropyridines
diltiazem extended release
verapamil immediate release
verapamil long acting
Verapamil
80-320

18. Class
Drug (Trade Name)
Usual Dose
Range in
mg/Day
Usual Daily
Frequency*
CCBs-dihydropyridines
amlodipine
nifedipine long-acting
2.5-10
30-60 1
Alpha-1
blockers
doxazosin
prazosin
terazosin
1-16
2-20
1-20
2-3
1-2
Central alpha-2 agonists and other
centrally acting drugs
clonidine
clonidine patch
methyldopa
reserpine
guanfacine
0.5-2 2
1 wkly
Direct vasodilators
hydralazine
minoxidil
25-100
2.5-80

19. Hypertension in Elderly
Pharmacological treatment:
- Lower initial doses (1/2 dose than in younger patients)
- The reduction in BP should be gradual
- Greater caution in patients with co-existing diseases or
orthostatic hypotension.
Choice of therapy:
- Thiazide diuretic (hydrochlorothiazide, HCTZ 12.5 mg)
- STOP-Hypertension trial: ACE inhibitors, long-acting calcium antagonist and beta- blockers may provide
the same protection as diuretics.

20. Hypertension in Elderly
Choice of therapy: special considerations
A diuretic should be used for heart failure or edema
A beta-blocker should be used for patient with coronary heart disease, tachyarrhitmias or migraine
An ACE inhibitors in patients with heart failure
Calcium antagonist should be used in patients with angina pectoris,and peripheral vascular disease
Alpha-blocker in patient with benign prostatic hyperplasia

21. Hypertension and Diabetes
Treatment:
Early treatment to prevent cardiovascular disease
and minimize progression of renal and retinal disease.
The benefits of tight blood pressure control in diabetics may be as great or greater than benefits of strict glycemic control.
Initial therapy should include non-pharmacological methods.
ACE Inhibitors, ARBs, C++ Channel Blockers,

22. Hypertension and Diabetes
Kidneys in diabetic patients are more sensitive
to any increase in blood pressure
Proteinuria is not only the marker of renal damage,
but also risk factor for progression of renal disease
Pathogenesis:

23. Asthma COPD and Hypertension
Beta-blockers (i) increase bronchial obstruction,
(ii) increase in airways reactivity, and (iii) inhibit the bronchodilatatory effects of beta agonist
Cardioselective, beta-blockers none should be considered safe.Even topical administration for the treatment of glaucoma may led to asthmatic exacerbations.
ACE inhibitors are not contraindicated and may be used; very rarely worsen airflow obstruction; produce persistent dry cough and are not first line drug for hypertensive patients with asthma or COPD.

24. Asthma COPD and Hypertension
Diuretics: can be effectively used but there is an increased risk of hypokalemia (inhaled b-2 agonist drive potassium into cell and orally administered corticosteroids mildly increase urinary potassium excretion).
Only low dose ( mg) of thiaizides to be used.
In patients with COPD and chronic hypercapnia, diuretics-induced metabolic alkalosis may suppress the ventilatory drive and exacerbates the hypoxia.

25. Asthma, COPD and Hypertension
Calcium channel blockers (CCB) are preferred for treatment of hypertension in astma & COPD. May be combined with diuretics
Short-acting CCB (niphedipine) should not be used because they increase CV risk.
Only long-acting CCB or slow-release niphedipine formulation should be used.

26. Ischemic Heart Disease and Hypertension
IHD is the most common form of target-organ damage associated with hypertension.
Beta blockers and long acting Ca++ channel blockers are the first choice in HTN patient with stable angina pectoris.
HTN patients with unstable angina or MI should be treated with beta blocker or ACE inhibitor.
In patients with post-myocardial infarction, ACE inhibitors, beta blockers and aldosterone antagonists; all reduce progression of left ventricular dysfunction and mortality.

27. Hart Failure and Hypertension
ACE inhibitors and beta blockers are recommended for HTN patients with asymptomatic ventricular dysfunction
In HTN patients with symptomatic ventricular dysfunction (NYHA III and IV) in addition to ACE inhibitors and beta blockers, treatment with diuretics, Ang II receptor antagonists and aldosterone antagonists.
In hypertensive HF patient, if volume depleted, ACE inhibitors may induce hypotension and acute renal failure. Beta blockers may induce initial/transient worsening of HF.

28. Pharmacotherapy of Hypertension
Pregnancy : Methyl Dopa, Hydralazine
Gout & Dyslipidemia: Avoid diuretics
Benign prostatic hypertrophy: Alfa-1 adrenergic
blockers

29. Pharmacotherapy of Hypertension
Alpha Blocker
AT1Antagonist
 - agonists
ACE Inhibitor
Ganglionic blockers
Dr. Rx
Rational
Drug of choice
Beta Blocker
Vasodilators
Ca++ Antagonist
Diuretic