What are examples of medications in different blood pressure classes, such as Diuretics (e.g. hydrochlorothiazide), Angiotensin-Converting Enzyme (ACE) inhibitors (e.g. lisinopril), Angiotensin Receptor Blockers (ARBs) (e.g. losartan), Calcium Channel Blockers (e.g. amlodipine), and Beta-Blockers (e.g. metoprolol)?

Examples of Medications in Different Blood Pressure Classes

The World Health Organization (WHO) recommends four main classes of antihypertensive medications as first-line treatment options: thiazide and thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and long-acting dihydropyridine calcium channel blockers. 1

Thiazide and Thiazide-like Diuretics

• Hydrochlorothiazide (HCTZ): Typically dosed at 12.5-25 mg daily, blocks sodium and chloride reabsorption in the distal tubule, increasing sodium and water excretion 2
• Chlorthalidone: 12.5-25 mg daily, preferred over other thiazides due to longer half-life and proven cardiovascular disease reduction 3
• Indapamide: Associated with fewer metabolic side effects compared to HCTZ 4

Angiotensin-Converting Enzyme (ACE) Inhibitors

• Lisinopril: Initial dose 10 mg once daily, usual maintenance dose 20-40 mg daily 5
• Enalapril: 5-40 mg daily, particularly beneficial in patients with diabetes, heart failure, and chronic kidney disease 3
• Perindopril: Shown to reduce cardiovascular events in patients with stable coronary artery disease 1
• Ramipril: Demonstrated reduction in cardiovascular events in high-risk patients 1
• Benazepril: Often combined with diuretics for enhanced blood pressure control 4

Angiotensin Receptor Blockers (ARBs)

• Losartan: 50-100 mg daily, shown in the LIFE study to reduce cardiovascular events better than beta-blockers in certain populations 1, 3
• Valsartan: Demonstrated benefit in heart failure patients 1
• Candesartan: Effective in heart failure management 1

Calcium Channel Blockers (CCBs)

Dihydropyridine CCBs

• Amlodipine: 2.5-10 mg daily, particularly effective in Black patients and elderly patients with isolated systolic hypertension 1, 3
• Felodipine: 2.5-20 mg daily 1
• Nifedipine (long-acting): 30-60 mg daily 1
• Nisoldipine: 10-40 mg daily 1

Non-dihydropyridine CCBs

• Diltiazem extended release: 180-420 mg daily 1
• Verapamil: 120-480 mg daily in various formulations 1
• Note: These should be avoided in patients with heart failure due to negative inotropic properties 1

Beta-Blockers

• Metoprolol: Effective antihypertensive agent at 100-450 mg daily, particularly useful when hypertension coexists with angina or post-myocardial infarction 6
• Carvedilol: Shown to improve outcomes in heart failure patients 1
• Bisoprolol: Beneficial in heart failure management 1
• Note: Beta-blockers are no longer considered first-line for uncomplicated hypertension due to reduced stroke prevention compared to other agents 3

Other Antihypertensive Classes

Alpha-1 Blockers

• Doxazosin: 1-16 mg daily 1
• Prazosin: 2-20 mg daily in divided doses 1
• Terazosin: 1-20 mg daily 1
• Caution: Should be avoided in heart failure patients due to increased risk 1

Central Alpha-2 Agonists

• Clonidine: 0.1-0.8 mg daily in divided doses 1
• Note: Moxonidine (same class) increased mortality in heart failure, so clonidine should be used cautiously 1

Direct Vasodilators

• Hydralazine: 25-100 mg daily in divided doses 1
• Minoxidil: 2.5-80 mg daily 1

Combination Therapy Considerations

• More than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents 7
• Effective two-drug combinations include:
  • Thiazide diuretic + ACE inhibitor 4
  • Thiazide diuretic + ARB 1
  • CCB + ACE inhibitor (particularly perindopril + amlodipine) 8, 9
  • CCB + ARB 1
• Important: ACE inhibitors and ARBs should not be used simultaneously as this increases adverse effects without additional benefit 3, 7

Special Population Considerations

• Black patients: Initial therapy should include a thiazide-type diuretic or CCB 3, 7
• Diabetes patients: ACE inhibitors or ARBs are preferred, especially with albuminuria 1, 3
• Chronic kidney disease patients: ACE inhibitors or ARBs are preferred, particularly with albuminuria ≥300 mg/day 1, 3
• Heart failure patients: Diuretics, ACE inhibitors (or ARBs), beta-blockers, and aldosterone receptor antagonists are recommended 1

Common Pitfalls to Avoid

• Combining ACE inhibitors with ARBs increases adverse effects without additional benefit 3
• Non-dihydropyridine CCBs (verapamil, diltiazem) should be avoided in heart failure patients 1
• Alpha blockers like doxazosin should be used only if other agents are inadequate for blood pressure control 1
• Short-acting CCBs are not recommended for hypertension management 1