1. Selection of Antihypertensive Drug

2. 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

3. Blood Pressure (mm Hg) Other risk and disease history Stage 1Stage 2 Stage 3 (severe hypertension) SBP 140-159 or DBP 90-99 SBP 160-179 or DBP 100-109 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

4. 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

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

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

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

8. ACE Inhibitors: Enalapril 5 -40 mg od – bd Ramipril 2.5 – 20mg od

9. ARBs: Losartan – 25 – 100 mg od – bd

10. 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.

11. 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

12. 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

13. - 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

14. - 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

15. - 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 - 250 to 500µg / kg / min for I minute, then 50 to 100µg / kg for 4 maintained

16. Hypertensive encephalopathy  Hydralazine- 10-50 mg IV / IM  Labetalol – 20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion  Magnesium IV

17. ClassDrug (Trade Name)Usual Dose Range in mg/Day Usual Daily mg/Day 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 221221 Potassium- sparing diuretics amiloride triamterene 5–10 50–100 1–2 Aldosterone receptor blockers eplerenone Spironolactone 50–100 25–50 1111

18. ClassDrug (Trade Name)Usual Dose Range in mg/Day Usual Daily mg/Day Frequency* BBsAtenolol Propranolol propranolol long-acting 25–100 40-160 60-180 121121 Combined alpha- and BBs Carvedilol labetalol 12.5–50 200–800 2222 ACEIsenalapril ramipril 5-40 2.5-20 1-2 1 Angiotensin II antagonists losartan25-1001-2 CCBs— nondihydropyr idines diltiazem extended release verapamil immediate release verapamil long acting Verapamil 180-420 120-540 80-320 120-480 120-360 1 2 1-2 1

19. ClassDrug (Trade Name)Usual Dose Range in mg/Day Usual Daily mg/Day Frequency* CCBs- dihydropyridi nes amlodipine nifedipine long-acting 2.5-10 30-60 1111 Alpha-1 blockers doxazosin prazosin terazosin 1-16 2-20 1-20 1 2-3 1-2 Central alpha- 2 agonists and other centrally acting drugs clonidine clonidine patch methyldopa reserpine guanfacine 0.1-0.8 0.1-0.3 250-1000 0.1-0.25 0.5-2 2 1 wkly 2 1 Direct vasodilators hydralazine minoxidil 25-100 2.5-80 2 1-2