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Update in pharmacologic treatment of hypertension
1Department of Clinical Pharmacology, Xavier University College of Pharmacy, New Orleans, Louisiana, USA. kcferdmd@aol.com
Insights
Initial hypertension treatments include diuretics, beta-blockers, and ACE inhibitors. Angiotensin-converting enzyme inhibitors offer specific benefits for patients with diabetes and kidney issues, guiding effective blood pressure management.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- Hypertension management involves multiple drug classes.
- Angiotensin-converting enzyme (ACE) inhibitors show particular benefits in specific patient groups.
- Calcium channel blockers (CCBs) and Angiotensin II Receptor Blockers (ARBs) are alternative agents with varying efficacy.
Purpose of the Study:
- To review initial pharmacologic therapies for hypertension.
- To highlight the specific benefits of ACE inhibitors in certain conditions.
- To discuss the comparative effectiveness of different antihypertensive agents and future therapeutic directions.
Main Methods:
- Review of existing data and clinical trials, including the ALLHAT trial.
- Comparative analysis of thiazide diuretics, beta-blockers, ACE inhibitors, CCBs, and ARBs.
- Examination of intensive pharmacologic treatment goals based on comorbidities.
Main Results:
- ACE inhibitors demonstrate specific benefits in patients with diabetes, atherosclerosis, left ventricular dysfunction, and renal insufficiency.
- CCBs may be alternatives for isolated systolic hypertension in the elderly but show less renal protection than ACE inhibitors.
- ARBs are effective but not yet proven superior to ACE inhibitors for renal or cardiovascular outcomes.
- Doxazosin is no longer recommended as an initial agent based on ALLHAT data.
Conclusions:
- Effective antihypertensive therapy is crucial for preventing cerebrovascular disease and cognitive dysfunction.
- Future agents like vasopeptidase inhibitors and endothelin-1 antagonists may offer new treatment options.
- Intensive blood pressure lowering is recommended for patients with diabetes, renal insufficiency, and heart failure, with stricter goals for those with proteinuria.
Abstract:
Initial pharmacologic therapy for hypertension is low-dose thiazide diuretics, beta-blockers, and ACE inhibitors. Increasing data have confirmed that ACE inhibitors have specific benefit in patients with diabetes, atherosclerosis, left ventricular dysfunction, and renal insufficiency. CCBs are alternative agents for ISH in the elderly and appear to decrease stroke with perhaps less protection against progression of renal insufficiency and proteinuria, CAD mortality and new onset heart failure versus other initial agents, especially ACE inhibitors. ARBs are well tolerated and effective blood pressure lowering agents but have not been confirmed as effective as ACE inhibitors for reducing renal progression, clinical events, or mortality from heart failure. Effective pharmacologic antihypertensive therapy may avoid disabling and undetected cerebrovascular disease, cognitive dysfunction, and disturbing symptoms of elevated blood pressure. Vasopeptidase inhibitor, such as omapatrilat, and endothelin-1 antagonist, such as bosentan, may become future agents approved for the reduction of morbidity and mortality with hypertension. The ALLHAT trial continues to examine the potential benefits and harms of amlodipine versus chlorthalidone and lisinopril in a diverse high-risk population. Based on ALLHAT data, however, doxazosin is no longer an acceptable initial pharmacological agent. Intensive pharmacologic treatment with blood pressure lowering to less than 130/85 mm Hg is recommended with diabetes, renal insufficiency, and heart failure with additional goal of less than 125/75 mm Hg with renal failure and proteinuria greater than 1 g/24 h, based on multiple outcome studies.