Pharmacologic options-Treatment-hypertension

Pre-HTN: ARB prevents onset of HTN, no ↓ in clinical events (NEJM 2006;354:1685) HTN: choice of therapy controversial, concomitant disease and stage may help guide Rx; ? improved control with nighttime administration (EHJ 2020;41:4564) Uncomplicated: CCB, ARB/ACEI, or thiazide (chlorthalidone preferred) are 1st line; βB not. For black Pts, reasonable to start with CCB or thiazide.

• CAD (Circ 2015;131:e435): ACEI or ARB; ACEI+CCB superior to ACEI+thiazide (NEJM 2008;359:2417) or βB+diuretic (Lancet 2005;366:895); may require βB and/or nitrates for anginal relief; if h/o MI, βB ± ACEI/ARB ± aldo antag (see “ACS”)
• HF: ARNI/ACEI/ARB, βB, diuretics, aldosterone antagonist (see “Heart Failure”)
• prior stroke: ACEI ± thiazide (Lancet 2001;358:1033)
• diabetes mellitus: ACEI or ARB; can also consider thiazide or CCB
• chronic kidney disease: ACEI or ARB (NEJM 2001;345:851 & 861)

• Tailoring therapy: if stage 1, start w/ monoRx; if stage 2, consider starting w/ combo (eg, ACEI + CCB; NEJM 2008;359:2417); start at ½ max dose; after ~1 mo, uptitrate or add drug
• Pregnancy: methyldopa, labetalol, & nifed pref. Hydral OK; avoid diuretics; Ø ACEI/ARB. Targeting DBP 85 vs. 105 safe and ↓ severe HTN (NEJM 2015;372:407).