Considerations in the individualization of antihypertensive therapy
| CONDITIONS | INITIAL THERAPY | SECOND-LINE THERAPY | ADDITIONAL NOTES |
|---|---|---|---|
| Hypertension without other compelling indications—Target BP < 140/90 mm Hg | |||
| Diastolic hypertension with or without systolic hypertension | Thiazide 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 target | Combinations of first-line drugs | β-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 indications | Thiazide diuretics, ARBs, or long- acting dihydropyridine CCBs | Combinations of first-line drugs | Same as above |
| Diabetes mellitus—Target BP < 130/80 mm Hg | |||
| Diabetes mellitus with nephropathy | ACE inhibitors or ARBs | Addition of thiazide diuretics, cardioselective β-blockers, long- acting CCBs, or an ARB and ACE inhibitor combination | If 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 nephropathy | ACE inhibitors, ARBs, dihydropyridine CCBs, or thiazide diuretics | Combination of first-line drugs or, if those are not tolerated, addition of cardioselective β-blockers or long-acting non-dihydropyridine CCBs | Normal 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 | |||
| Angina | β-Blockers and ACE inhibitors except in low-risk patients | Long-acting CCBs | Avoid short-acting nifedipine |
| Prior myocardial infarction | βBlockers and ACE inhibitors (use ARBs in ACE inhibitor– intolerant patients) | Long-acting CCBs | None |
| Heart failure | ACE inhibitors (ARBs if ACE inhibitor–intolerant) and β-blockers; spironolactone in patients with NYHA class III or IV symptoms | ARBs 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 hypertrophy | ACE inhibitors, ARBs, dihydropyridine CCBs, diuretics, (β-blockers in patients < 55 y) | None | Avoid hydralazine and minoxidil |
| Past cerebrovascular accident or TIA | ACE inhibitor and diuretic combinations | None | This 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 proteinuria | ACE inhibitors (ARBs if ACE inhibitor–intolerant), with diuretics as additive therapy | Combinations of additional agents | Avoid 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 disease | Similar to diastolic with or without systolic hypertension without compelling indications for other medications | None | Avoid 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 disease | Does not affect initial treatment recommendations | Does not affect initial treatment recommendations | Avoid β-blockers in patients with severe onset of disease |
| Dyslipidemia | Does not affect initial treatment recommendations | Does not affect initial treatment recommendations | None |
| Global vascular protection | Statin therapy in patients with 3 or more cardiovascular risk factors or with atherosclerotic disease. Low-dose ASA in patients with controlled BP | None | Caution 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.