Blood Pressure Medications
Blood Pressure Medications
For certain individuals with high blood pressure, or hypertension, taking blood pressure-lowering medications (ie, antihypertensives) can be helpful in managing their blood pressure (BP) as well as cardiovascular risks.1 Although lifestyle modification is the first line treatment for hypertension, antihypertensives may become necessary for individuals with certain hypertensive characteristics.2
According to the 2017 American Heart Association (AHA) guidelines, nonpharmacological therapy is first recommended for those with elevated blood pressure (BP 120-129/<80 mm Hg) and those with stage 1 hypertension (BP 130-139/80-89 mm Hg) with <10% 10-year cardiovascular disease (CVD) risk.1 Blood pressure should be reassessed in 3-6 months to determine whether pharmacological treatment can be beneficial. For those with stage 1 hypertension with >10% 10-year CVD risk and those with stage 2 hypertension (BP >140/90 mm Hg), antihypertensive medication(s) should be initiated. Additionally, the 2020 International Society of Hypertension recommends that immediate antihypertensive treatment should begin in individuals already with CVD, chronic kidney disease (CKD), diabetes mellitus, or hypertension-mediated organ damage.2
Information and recommendations on the following commonly prescribed oral antihypertensives come from the 2017 AHA guideline on the management of hypertension:1
- Thiazide or thiazide-type diuretics
- ACE (angiotensin-converting enzyme) inhibitors
- ARBs (angiotensin receptor blockers)
- CCBs (calcium channel blockers)
- Diuretics
- Beta blockers
PRIMARY AGENTS:
Thiazide or thiazide-type diuretics, ACE inhibitors, ARBs, and CCBs are the recommended first-line medications when starting antihypertensive drugs.1 ACE inhibitors and ARBs should not be used in combination with each other. They are also contraindicated in pregnancy. Thiazide diuretics, ACE inhibitors, ARBs, or their combination can be useful for individuals who have had a stroke or a transient ischemic attack (ie, brief stroke) in the past. All primary agents are useful and effective for individuals with hypertension and diabetes. In black adults with hypertension without heart failure or CKD are recommended to begin treatment with either a thiazide diuretic or a CCB.
THIAZIDE or THIAZIDE-TYPE DIURETICS
How thiazide diuretics work is not yet fully understood.3 Researchers believe it blocks Na/Cl channels and inhibits sodium reabsorption, thereby reducing volume and blood pressure. It may also have modest vasodilation (ie, dilation of blood vessels) effect.
Thiazide or thiazide-type diuretics include:1
- Chlorthalidone
- Hydrochlorothiazide
- Indapamide
- Metolazone
ACE INHIBITORS
ACE inhibitors work by inhibiting angiotensin-converting enzyme, which leads to decreased angiotensin II levels and increased bradykinin levels, causing vasodilation.3 This leads to decreased blood pressure. ACE inhibitors are preferred in individuals with CKD as it can slow kidney disease progression.1
ACE inhibitors include:
- Benazepril
- Enalapril
- Lisinopril
- Ramipril
- Trandolapril
ARBs
ARBs work by blocking angiotensin II from binding to angiotensin 1 AT1 receptors, inhibiting the angiotensin II effect, also leading to vasodilation and decrease in blood pressure.3 When ACE inhibitors are not tolerated in individuals with CKD and hypertension, ARBs should be considered.1
ARBs include:
- Azilsartan
- Eprosartan
- Losartan
- Valsartan
CCBs
CCBs work by inhibiting calcium ion entry to cells.3 CCB-dihydropyridines cause vasodilation and CCB-nondihydropyridines cause heart contractility and conduction to slow, leading to decreased blood pressure. Addition of CCB-dihydropyridines (e.g., amlodipine) may be recommended in individuals with stable ischemic heart disease with angina (ie, chest pain) and persistently uncontrolled hypertension.1 CCB-nondihydropyridines (e.g., verapamil) should be avoided in individuals with heart failure with reduced ejection fraction.
CCBs include:
- Amlodipine
- Isradipine
- Nifedipine
- Diltiazem
- Verapamil
SECONDARY AGENTS:
Secondary agents may be used as additions to primary agents, or as first-line therapies when there are compelling indications based on previous or coexisting comorbidities or risks.
DIURECTICS
Diuretics work on various levels of the kidney to reduce sodium reabsorption, causing decrease in volume and in blood pressure.3 Individuals with symptomatic heart failure with preserved ejection fraction are recommended diuretics.1 Loop diuretics are also preferred in patients with moderate-to-severe CKD. Aldosterone antagonist diuretics such as spironolactone are recommended in primary aldosteronism and resistant hypertension.
Diuretics include:
- Bumetanide
- Furosemide
- Amiloride
- Spironolactone
BETA BLOCKERS
Beta blockers work by inhibiting catecholamines (ie, a type of neurotransmitter) from binding to beta receptors.3 Blocking its binding to beta receptors in the heart reduces heart contractility and conduction, leading to decreased heart rate as well as blood pressure. Beta blockers may be recommended as first-line therapy in case of previous myocardial infarction (ie, heart attack), stable angina, or acute coronary syndrome.1 Certain beta blockers such as those that are cardioselective (e.g., atenolol) or combined alpha- and beta-receptor (e.g., carvedilol) are recommended in individuals with ischemic heart disease or heart failure, including heart failure with reduced ejection fraction. Cardioselective beta blockers are also preferred in individuals with bronchospastic airway disease.
Beta blockers include:
- Atenolol
- Metoprolol
- Nebivolol
- Propranolol
- Acebutolol
- Carvedilol
- Labetalol
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