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Antihypertensives (unfinished)


Learning objectives

  • Therapeutic uses of Antihypertensives
  • Contraindications

Introduction

Diagnosis and management of BP is well documented by the NICE guidelines published in 2001 Here.

  • Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
  • Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
  • Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.

Classes Used and abbreviations

  • Angiotensin-converting enzyme (ACE) inhibitor
  • Angiotensin-II receptor blocker (ARB)
  • Calcium channel blocker (CCB)
  • Thiazide Like Diuretic (TZD)
  • Loop diuretic (LD)
  • Beta Blockers (BB)

Pharmacology of Common Antihypertensives

Name and BNF linkClassDoseSide effectsNotes
Indapamide TZD1.5 mg modified-release once daily or 2.5 mg once dailySide effectsNotes
RamiprilACEIStart 1.25–2.5 mg OD, increased if necessary up to 10 mg once daily, dose to be increased at intervals of 2–4 weeksSide effectsNotes
Name and BNF linkClassDoseSide effectsNotes
Name and BNF linkClassDoseSide effectsNotes
Name and BNF linkClassDoseSide effectsNotes

Evidence base

Patients under 55 years:

  • Step 1: ACEI; if not tolerated, offer an ARB. If both ACEI and ARB are contra-indicated or not tolerated, consider a BB; BB, especially when combined with a TZD, should be avoided for the routine treatment of uncomplicated hypertension in patients with diabetes or at high risk of developing diabetes
  • Step 2: ACEI or ARB in combination with a CCB. If a CCB is not tolerated or if there is evidence of, or a high risk of, heart failure, give a TZD (e.g. chlortalidone or indapamide). If a BB was given at Step 1, add a CCB in preference to a TZD (see Step 1)
  • Step 3: ACEI or ARB in combination with a CCB and a TZD
  • Step 4 (resistant hypertension): Consider seeking specialist advice
  • Add low-dose spironolactone [unlicensed indication], or use high-dose TZD if plasma-potassium concentration above 4.5 mmol/litre
  • Monitor renal function and electrolytes

    If additional diuretic therapy is contra-indicated, ineffective, or not tolerated, consider an alpha-blocker or a beta-blocker

Patients over 55 years, and patients of any age who are of African or Caribbean family origin:

  • Step 1: CCB; if not tolerated or if there is evidence of, or a high risk of, heart failure, give a TZD (e.g. chlortalidone or indapamide)
  • Step 2: CCB or TZD in combination with an ACEI or ARB (an ARB in combination with a CCB is preferred in patients of African or Caribbean family origin)
  • Steps 3 and 4: Treat as for patients under 55 years. Cardiovascular risk reduction.

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