What is the appropriate antihypertensive (Blood Pressure) medication to prescribe?

From the Guidelines

When selecting a blood pressure medication, ACE inhibitors, ARB, CCB, or diuretics are recommended as first-line treatments, with initial combination therapy often favored, especially in patients with hypertension and high cardiovascular risk. The choice of medication should be guided by the presence of comorbidities, with specific considerations for patients with coronary heart disease, diabetes, or kidney disease 1. Key factors to consider include:

• The patient's blood pressure levels, with treatment considered for adults with SBP ≥140 mm Hg or DBP ≥90 mm Hg, and in those with SBP 130–139 mm Hg or DBP 85–89 mm Hg who are at very high risk due to cardiovascular disease (CVD) 1.
• The use of single-pill combinations is strongly favored for initial combination therapy, which may include ACE inhibitors or ARB plus CCB or diuretic 1.
• If blood pressure remains above goal, switching to a single-pill combination with ACE inhibitors or ARB plus CCB and diuretic is recommended, with the addition of spironolactone or other diuretics, α-blocker, or β-blocker considered if necessary 1.
• The simultaneous use of ACE inhibitors and ARB is not recommended due to increased risk of adverse effects 1.
• Beta-blockers are considered first-line antihypertensive drugs in patients with specific indications for their use, such as cardiac conditions or pregnancy, but are generally equivalent to other BP-lowering drugs in preventing major cardiovascular events, except for less efficacy in stroke prevention 1. It is essential to monitor blood pressure response, electrolytes, and kidney function after starting therapy and to accompany medication with lifestyle modifications, including sodium restriction, weight loss, regular exercise, and limiting alcohol consumption.

From the FDA Drug Label

Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.

The choice of BP medication to prescribe depends on various factors, including:

• Patient population: Different medications may be more effective in certain populations, such as black patients or patients with diabetes or hyperlipidemia.
• Additional indications: Medications with additional approved indications, such as angina or heart failure, may be preferred in patients with these conditions.
• Mechanism of action: Different medications have different mechanisms of action, which may be beneficial in certain situations. It is essential to consider these factors and published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), when selecting a BP medication 2 3.

From the Research

Choosing the Right BP Medication

To determine which BP medication to prescribe, several factors must be considered, including the patient's medical history, current medications, and potential side effects.

• The 2018 ESH/ESC guidelines recommend a fixed combination of a drug that blocks the renin-angiotensin-aldosterone system and a calcium antagonist or a diuretic as first-choice therapy in the majority of hypertensive patients 4.
• ACE inhibitors have been shown to outperform AT-1 antagonists in preventing myocardial infarction and total mortality, making them a preferred choice 4.
• The combination of an ACE inhibitor and a calcium antagonist, such as ramipril and amlodipine, has been demonstrated to be effective in reducing cardiovascular events and is considered a first-choice therapy for hypertension 4.
• Other studies have compared the efficacy of different combination therapies, including ARB-diuretic and ARB-calcium channel blocker combinations, with mixed results 5, 6.
• The choice of combination therapy may depend on the individual patient's characteristics, such as prior history of cerebrovascular accident, and the presence of other medical conditions, such as heart failure or African American origin 6, 7.

Considerations for Specific Patient Populations

• In patients with prior history of cerebrovascular accident, adding a diuretic to ACEIs/ARBs and CCBs may be more effective than adding a beta-blocker in reducing the risk of acute myocardial infarction 7.
• In patients with heart failure, the combination of a RAAS inhibitor with a diuretic may be beneficial 6.
• In patients of African American origin, the combination of a RAAS inhibitor with a diuretic may also be effective 6.

Key Takeaways

• The choice of BP medication should be individualized based on the patient's specific needs and characteristics.
• Combination therapy is often necessary to achieve target blood pressure levels and reduce cardiovascular risk.
• The combination of an ACE inhibitor and a calcium antagonist is a recommended first-choice therapy for hypertension, but other combinations may be effective in specific patient populations 4, 6, 7.