Table 3

Considerations in the individualization of antihypertensive therapy

CONDITIONSINITIAL THERAPYSECOND-LINE THERAPYADDITIONAL NOTES
Hypertension without other compelling indications—Target BP < 140/90 mm Hg
Diastolic hypertension with or without systolic hypertensionThiazide diuretics, β-blockers, ACE inhibitors, ARBs, or long- acting CCBs (consider ASA and statins in selected patients). Consider initiating therapy with a combination of 2 first-line drugs if BP is ≥ 20 mm Hg systolic or ≥ 10 mm Hg diastolic above targetCombinations of first-line drugsβ-Blockers are not recommended initial therapy in those > 60 y. Hypokalemia should be avoided by using potassium-sparing agents for those who are prescribed diuretics as monotherapy. ACE inhibitors are not recommended for black patients. ACE inhibitors and ARBs are teratogenic and caution is required if prescribing to women with childbearing potential
Isolated systolic hypertension without other compelling indicationsThiazide diuretics, ARBs, or long- acting dihydropyridine CCBsCombinations of first-line drugsSame as above
Diabetes mellitus—Target BP < 130/80 mm Hg
Diabetes mellitus with nephropathyACE inhibitors or ARBsAddition of thiazide diuretics, cardioselective β-blockers, long- acting CCBs, or an ARB and ACE inhibitor combinationIf the serum creatinine level is > 150 μmol/L, a loop diuretic should be used as a replacement for low-dose thiazide diuretics (if volume control is required)
Diabetes mellitus without nephropathyACE inhibitors, ARBs, dihydropyridine CCBs, or thiazide diureticsCombination of first-line drugs or, if those are not tolerated, addition of cardioselective β-blockers or long-acting non-dihydropyridine CCBsNormal albumin to creatinine ratio < 2.0 mg/mmol in men and < 2.8 mg/mmol in women
Cardiovascular and cerebrovascular disease—Target BP < 140/90 mm Hg
Anginaβ-Blockers and ACE inhibitors except in low-risk patientsLong-acting CCBsAvoid short-acting nifedipine
Prior myocardial infarctionβBlockers and ACE inhibitors (use ARBs in ACE inhibitor– intolerant patients)Long-acting CCBsNone
Heart failureACE inhibitors (ARBs if ACE inhibitor–intolerant) and β-blockers; spironolactone in patients with NYHA class III or IV symptomsARBs or hydralazine/isosorbide dinitrate (thiazide or loop diuretics as additive therapy)Titrate doses of ACE inhibitors and ARBs to those used in clinical trials. Avoid non-dihydropyridine CCBs (diltiazem, verapamil). Monitor potassium and renal function if combining ACE inhibitors and ARBs
Left ventricular hypertrophyACE inhibitors, ARBs, dihydropyridine CCBs, diuretics, (β-blockers in patients < 55 y)NoneAvoid hydralazine and minoxidil
Past cerebrovascular accident or TIAACE inhibitor and diuretic combinationsNoneThis does not apply to acute stroke. BP reduction reduces recurrent cerebrovascular events in patients with stable past cerebrovascular disease. BP lowering should be considered in those with normal BP who have had strokes
Non-diabetic chronic kidney disease—Target BP < 130/80 mm Hg
Non-diabetic chronic kidney disease with proteinuriaACE inhibitors (ARBs if ACE inhibitor–intolerant), with diuretics as additive therapyCombinations of additional agentsAvoid ACE inhibitors or ARBs in patients with bilateral renal artery stenosis or unilateral disease with solitary kidney. Patients taking ACE inhibitors or ARBs should have their serum creatinine and potassium carefully monitored
Renovascular diseaseSimilar to diastolic with or without systolic hypertension without compelling indications for other medicationsNoneAvoid ACE inhibitors or ARB in patients with bilateral renal artery stenosis or unilateral disease with solitary kidney. Patients placed on ACE inhibitors or ARBs should have their serum creatinine and potassium carefully monitored
Other conditions—Target BP < 140/90 mm Hg
Peripheral arterial diseaseDoes not affect initial treatment recommendationsDoes not affect initial treatment recommendationsAvoid β-blockers in patients with severe onset of disease
DyslipidemiaDoes not affect initial treatment recommendationsDoes not affect initial treatment recommendationsNone
Global vascular protectionStatin therapy in patients with 3 or more cardiovascular risk factors or with atherosclerotic disease. Low-dose ASA in patients with controlled BPNoneCaution should be exercised with the ASA recommendation if BP is not controlled
  • ACE—angiotensin-converting enzyme, ARB—angiotensin II receptor blocker, ASA—acetylsalicylic acid, BP—blood pressure, CCB—calcium channel blocker, NYHA—New York Heart Association, TIA—transient ischemic attack.

  • Reprinted with permission from the Canadian Hypertension Education Program.