The drug selections for these compelling indications are based on favorable outcome data from clinical trials. A combination of agents may be required. Other management considerations include medications already in use, tolerability, and desired blood pressure targets. In many cases, specialist consultation may be indicated.
Ischemic Heart Disease
Ischemic heart disease (IHD) is the most common form of target organ damage associated with hypertension. In patients with hypertension and stable angina pectoris, the first drug of choice is usually a beta blocker; alternatively, long-acting calcium channel blockers can be used. In patients with acute coronary syndromes (unstable angina or myocardial infarction), hypertension should be treated initially with beta blockers and angiotensin converting enzyme inhibitors, with addition of other drugs as needed for blood pressure control. In patients with postmyocardial infarction, angiotensin converting enzyme inhibitors, beta blockers, and aldosterone antagonists have proven to be most beneficial. Intensive lipid management and aspirin therapy are also indicated.
Heart failure (HF), in the form of systolic or diastolic ventricular dysfunction, results primarily from systolic hypertension and IHD. Fastidious blood pressure and cholesterol control are the primary preventive measures for those at high risk for HF. In asymptomatic individuals with demonstrable ventricular dysfunction, angiotensin converting enzyme inhibitors and beta blockers are recommended. For those with symptomatic ventricular dysfunction or end-stage heart disease, angiotensin converting enzyme inhibitors, beta blockers, angiotensin receptor blockers and aldosterone blockers are recommended along with loop diuretics.
Combinations of two or more drugs are usually needed to achieve the target goal of <130/80 mmHg. Thiazide diuretics, beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers are beneficial in reducing CVD and stroke incidence in patients with diabetes. ACEI- or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria, and angiotensin receptor blockers have been shown to reduce progression to macroalbuminuria.
Chronic Kidney Disease
In people with chronic kidney disease (CKD), as defined by either:
Hypertension appears in the majority of these patients, and they should receive aggressive blood pressure management, often with three or more drugs to reach target blood pressure values of <130/80 mmHg. angiotensin converting enzyme inhibitors and angiotensin receptor blockers have demonstrated favorable effects on the progression of diabetic and nondiabetic renal disease. A limited rise in serum creatinine of as much as 35 percent above baseline with angiotensin converting enzyme inhibitor or angiotensin receptor blockers is acceptable and is not a reason to withhold treatment unless hyperkalemia develops.65 With advanced renal disease (estimated GFR <30 ml/min 1.73 m2, corresponding to a serum creatinine of 2.5–3 mg/dL), increasing doses of loop diuretics are usually needed in combination with other drug classes.
The risks and benefits of acute lowering of blood pressure during an acute stroke are still unclear; control of blood pressure at intermediate levels (approximately 160/100 mmHg) is appropriate until the condition has stabilized or improved. Recurrent stroke rates are lowered by the combination of an ACEI and thiazide-type diuretic.