Treatment of hypertension from volume to vasoconstriction: The ACE up your sleeve

Control of hypertension in the vascular patient is clearly a priority. However, these patients often will have significant co-morbidities that may influence the choice of medication, a decision that also may be affected by cost or Health Plan directives. Wherever possible, monotherapy should be attempted first, although in select circumstances combination therapy may be more appropriate. The 5 main categories of drugs used in the initial treatment of hypertensive vascular diseases are (1). diuretics, (2). beta-adrenergic blockers, (3). calcium channel blockers, (4). angiotensin-converting enzyme (ACE) inhibitors, and (5). angiotensin receptor blockers (ARBs). There are also other less commonly used drugs. Each of the antihypertensive agents is roughly equally effective, producing a good antihypertensive response in 40% to 60% of cases. Some antihypertensives, especially ACE and ARBs, also may have beneficial effects on the vascular and metabolic systems separate from their blood pressure lowering effects, which suggests they may be beneficial even if blood pressure is well maintained with other agents. This report covers the basic information required for the vascular surgeon to become familiar with the various medications and their indications, dosage, and side effects. It also provides some guidelines in selecting relevant antihypertensive treatment regimens for the elderly patient with arterial vascular disease.