First line agents for hypertension are one of three classes:
- ACE inhibitors or Angiotensin receptor blockers
- Thiazides
- Calcium channel blockers
Drug preference is mainly influenced by co-morbidities and contraindications, rather than a simple age cut-off.
Co-morbidities & Preferred anti-hypertensive agents
Renal dysfunction, Microalbuminuria, ESRD, Proteinuria
ACEi/ARB
Prior MI
bB, ACEi/ARB
Angina
bB, CCB
Heart failure
Diuretics, bB, ACEi/ARB, spironolactone
AF, prevention
ARB/ACEi, bB, spironolactone
AF, rate control
bB, Diltiazem
Metabolic syndrome
ACEi/ARB, CCB
Isolated systolic hypertension in elderly
Diuretics, CCB
Pregnancy
Methyldopa (category B);
bB, CCB (category C)
Diabetes
ACEi/ARB
Aortic aneurysm
bB
Peripheral arterial disease
ACEi, CCB
Anti-hypertensives agents & Contraindications
Thiazides
Gout. Metabolic syndrome. Glucose intolerance, Pregnancy, Hypercalcaemia, Hypokalaemia
Beta-blockers
Asthma. AV block. Metabolic syndrome. Glucose intolerance. Athletes and physically active patients. COPD unless vasodilator bB.
Dihydropyridines CCB
Tachyarrhythmia. ?Heart failure.
Verapamil, Diltiazem CCB
AV block. Severe LV dysfcuntion. Heart failure.
ACEi / ARB
Pregnancy. Women with child bearing potential. Angioneurotic oedema.
HyperK. Bilateral renal artery stenosis
Spironolactone
Acute or severe renal failure. HyperK
Author: Dr Andrew To