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Alternative pharmacologic approaches to the initial management of hypertension
Insights
Aggressive blood pressure control with diuretics in hypertension may increase coronary heart disease deaths. Alternative antihypertensive drugs are recommended for specific patient groups to improve cardiovascular outcomes.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Recent hypertension trials show increased coronary heart disease (CHD) deaths in mild hypertensives receiving aggressive drug therapy.
- Subset analyses suggest diuretic therapy may contribute to this outcome via potassium reduction or lipid elevation.
Purpose of the Study:
- To identify alternative antihypertensive agents for patients at risk due to diuretic therapy.
- To review literature on effective alternatives to thiazide therapy in hypertension management.
Main Methods:
- Literature review of clinical trials and antihypertensive drug efficacy.
- Analysis of potential adverse effects of diuretic therapy (hypokalemia, hyperlipidemia).
Main Results:
- Beta-blockers, prazosin, captopril, and hydralazine are effective alternatives to thiazides for specific patient subgroups.
- Sympatholytic monotherapy is not recommended due to side effects and lower efficacy.
- Calcium channel blockers show promise but require more data.
Conclusions:
- Alternative antihypertensive pharmacologic agents should be considered for patients with specific risk factors.
- Drug selection may be influenced by patient age and race.
- Further research is needed on calcium channel blockers as alternatives.
Abstract:
Recent clinical trials in hypertension report more deaths due to coronary heart disease in mild hypertensives who received aggressive antihypertensive drug therapy and achieved better blood pressure control. Subset analyses of these trials suggest that diuretic therapy may have contributed to this outcome, possibly through a reduction in serum potassium or an elevation in serum lipids. Because of this, patients with an abnormal pretreatment electrocardiogram, history of myocardial infarction, unstable coronary heart disease, or diuretic-induced hyperlipidemia or hypokalemia unresponsive to management are candidates for alternative antihypertensive agents. A review of the literature suggests that most of the currently available beta-blockers, the alpha 1-antagonist prazosin, the angiotensin-converting enzyme inhibitor captopril, and the vasodilator hydralazine are effective alternatives to thiazide therapy in the initial management of hypertension and are recommended for particular subgroups of patients. Monotherapy with the centrally and peripherally acting sympatholytic agents is not recommended because of the frequent side effects encountered and the inferior hypotensive efficacy reported. Calcium channel blocking agents also appear to be suitable alternatives to thiazides in hypertension, but more experience with these is needed. Alternative pharmacologic agents may be selected on the basis of age, and, to a lesser extent, race.