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

  
    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

  
    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