Comorbidities to Consider and Antihypertensive Selection
When prescribing antihypertensive medications, it is essential to assess for specific comorbidities that will guide drug selection, as certain medications are preferred or contraindicated based on coexisting conditions.
Key Comorbidities to Assess
- Coronary Artery Disease (CAD): Favors ACE inhibitors, ARBs, and beta-blockers as first-line therapy 1
- Heart Failure:
- Diabetes: ACE inhibitors or ARBs, especially if albuminuria is present 1
- Chronic Kidney Disease: ACE inhibitors or ARBs are preferred 1
- Atrial Fibrillation: ARBs may reduce recurrence 1
- Stroke History: Thiazide diuretics, ACE inhibitors, or ARBs 1
- Peripheral Arterial Disease: Consider standard first-line drugs 1
- Post-Myocardial Infarction: Beta-blockers and ACE inhibitors/ARBs 1
- Aortic Disease: Beta-blockers are favored in thoracic aortic disease 1
- Post-Kidney Transplant: Calcium channel antagonists can improve kidney graft survival 1
- Benign Prostatic Hypertrophy: Alpha-blockers may be beneficial 1
- Gout: Thiazide diuretics should be used with caution 1
- Asthma/COPD: Beta-blockers are contraindicated 1
- Pregnancy: ACE inhibitors and ARBs are contraindicated 2
Antihypertensive Selection Algorithm
Step 1: Initial Assessment
- Determine if patient has compelling indications for specific drug classes 1
- Check for contraindications to specific medications 1
- Assess cardiovascular risk factors and target organ damage 1
Step 2: First-Line Medication Selection
- No compelling indications: Choose from diuretics, ACE inhibitors, ARBs, or calcium channel blockers 1
- With compelling indications: Select medication based on comorbidity table below 1
Step 3: Combination Therapy (if needed)
- For most patients, especially those with BP ≥20/10 mmHg above target, combination therapy is required 1
- Use drugs with complementary mechanisms of action 1
- Consider single-pill combinations to improve adherence 1
- Avoid combining ACE inhibitors with ARBs 1
Preferred Medications by Comorbidity
| Comorbidity | Preferred Medications | Medications to Avoid |
|---|---|---|
| Coronary Artery Disease | ACE inhibitors, ARBs, beta-blockers [1] | - |
| Heart Failure (reduced EF) | GDMT beta-blockers, ACE inhibitors, ARBs [1] | Non-dihydropyridine calcium antagonists [1] |
| Heart Failure (preserved EF) | Diuretics, ACE inhibitors, ARBs [1] | - |
| Diabetes with albuminuria | ACE inhibitors, ARBs [1] | - |
| Chronic Kidney Disease | ACE inhibitors, ARBs [1] | Use with caution and monitoring [1] |
| Atrial Fibrillation | ARBs [1] | - |
| Post-stroke | Thiazides, ACE inhibitors, ARBs [1] | - |
| Aortic disease | Beta-blockers [1] | - |
| Asthma/COPD | - | Beta-blockers [1] |
| Benign Prostatic Hypertrophy | Alpha-blockers [1] | - |
| Pregnancy | - | ACE inhibitors, ARBs [2] |
| Gout | - | Thiazides (use with caution) [1] |
Lifestyle Modifications
Always recommend these alongside pharmacological therapy 1:
- Sodium restriction to <1500 mg/day or reduction of at least 1000 mg/day 1
- Increased dietary potassium (3500-5000 mg/day) 1
- Weight loss if overweight/obese 1
- Physical activity (aerobic or resistance exercise) 1
- Moderation of alcohol intake 1
- DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1
Follow-Up and Monitoring
- For patients initiating drug therapy: Follow-up approximately monthly until BP is controlled 1
- After BP goal is achieved: Follow-up every 3-6 months 1
- Monitor serum potassium and creatinine at least 1-2 times per year 1
- Consider home BP monitoring to assess control 1
Common Pitfalls to Avoid
- Inadequate dosing: Titrate medications to effective doses before adding additional agents 1
- Inappropriate combinations: Avoid combining ACE inhibitors with ARBs 1
- Overlooking orthostatic hypotension risk: Use caution when initiating therapy in elderly patients and those with autonomic dysfunction 1
- Ignoring drug interactions: Be aware of potential interactions, especially with calcium channel blockers like diltiazem and verapamil which inhibit CYP3A4 3
- Not considering medication adherence: Single-pill combinations may improve adherence 1
Remember that most patients will require multiple medications to achieve blood pressure goals, especially those with diabetes or chronic kidney disease where targets are lower 1, 4.