Choosing the right hypertension medication for your patient

What is the most suitable antihypertensive agent for the general population? How does the recommendation change when the patient has diabetes or albuminuria? Would your drug of choice differ for Black patients? What antihypertensive drugs should you avoid in patients who want to get pregnant? In this video, Franz presents the answers based on the American College of Cardiology and American Heart Association (ACC / AHA) 2017 guidelines.

Franz Wiesbauer, MD MPH
Franz Wiesbauer, MD MPH
11th Mar 2022 • 4m read
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What is the most suitable antihypertensive agent for the general population? How does the recommendation change when the patient has diabetes or albuminuria? Would your drug of choice differ for Black patients? What antihypertensive drugs should you avoid in patients who want to get pregnant? In this video, Franz presents the answers based on the American College of Cardiology and American Heart Association (ACC / AHA) 2017 guidelines.

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With so many antihypertensive agents to choose from, determining which medications to use can be daunting. In this course, we’ll break down the most recent hypertension guidelines and tell you when to use (or not to use) the top four, first-line agents. This will help you to quickly and effectively make treatment decisions for the majority of your patients.

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Video transcript

Now that you know the key players when it comes to medications, how do you decide which one to use as a first line therapy for your patient? Well, all the possible options are way more than what we could pack into this course. But let's look at some general guidelines based on some common patient characteristics and comorbidities.

These guidelines are meant to help you navigate the initial management of a patient with hypertension. When determining which classes or specific drugs to prescribe, always consider your patient's unique situation and history. For the general population, your best first line agents are usually thiazides, calcium channel blockers, ACE inhibitors, or ARBs. Thiazides are often the first choice and there's evidence that they may be better at preventing heart failure than calcium channel blockers.

For patients who have maintained good lifestyle choices and significantly reduced their sodium intake, but still require medication, there's evidence that they may respond better to ACE inhibitors or ARBs. But ultimately, your choice will depend on your patient's history and clinical situation. Beta blockers are no longer a first choice for the general population. For patients with diabetes, all your first line options will be the same as for the general population. However, if your patient has albuminuria, you may consider starting with an ACE inhibitor or ARB since these drugs have been shown to slow progression of albuminuria, and help preserve kidney function.

Similarly, for patients with chronic kidney disease, ACE inhibitors, or ARBs, are going to be your first line therapy, especially if the patient has albuminuria. For black patients a thiazide, or a calcium channel blocker should be your first line therapy options. Studies have shown that ACE inhibitors and ARBs are less effective at preventing stroke in black patients as compared to thiazides or calcium channel blockers. If you're starting two agents, it's reasonable to choose an ACE inhibitor or ARB along with a thiazides or calcium channel blocker.

But if you have to choose only one, best to stay away from the RAS inhibitors, this is true even for patients with diabetes. However, for black patients with diabetic nephropathy, you will still get the best response by using an ACE inhibitor or ARB first. The treatment of hypertension during pregnancy is outside the scope of this course, but for patients who plan to become pregnant, your choices are more limited. Your best bets are usually a calcium channel blocker like nigrfipine or a beta blocker such as labetalol.

Methyldopa, as an alpha-2 agonist is also a safe first line choice. You'll want to avoid ACE inhibitors and ARBs in patients who may become pregnant as these can harm the fetus. For patients with a recent myocardial infarction or heart failure, this is where the beta blocker will be our first choice followed by an ACE inhibitor or ARB. And lastly, for patients with stable coronary artery disease, we may choose an ACE inhibitor or ARB followed by a beta blocker or calcium channel blocker.

What about sex differences? As it turns out, other than pregnancy related considerations, there's no evidence that antihypertensive treatments or blood pressure targets should be different between males and females. That said, some studies suggest that side effects of antihypertensive therapy may be more common in women than in men, so that might be something to watch out for.