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: p receptor antagonists, ACE inhibitors/A^ 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, post-myocardial 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, p receptor antagonist, ACE inhibitor/AT1 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 antihy-pertensive drugs. For example, a hypertensive patient with symptomatic benign prostatic hyperpla-sia 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 p 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 Ca2+ 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 life-threatening 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.
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