Hypertension is the one of the most common cardiovascular conditions that must be treated aggressively to prevent any complication, including myocardial infarction, stroke, renal failure, and death.
According to the JNC 8 guidelines, hypertensive patients over 60 years old must be treated with a blood pressure goal of less than 150/ 90 mm HG, while younger hypertensive patients (less than 60 years) should be treated with a goal of less than 140/90 mm Hg including diabetic patients and patients with chronic kidney disease.
Initial treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). Except for black population, treatment should include a thiazide-type diuretic or CCB.
The JNC 8 did not recommend β-blockers for the initial treatment of hypertension because it resulted in a higher rate of cardiovascular death, myocardial infarction, or stroke compared to use of an ARB.
Also they don’t recommend using α-Blockers as first-line therapy because in one study initial treatment with an α-blocker resulted in worse cerebrovascular, heart failure, and combined cardiovascular outcomes than initial treatment with a diuretic.
According to studies Initial treatment with a thiazide-type diuretic was more effective than a CCB or ACEI for preventing heart failure, and an ACEI was more effective than a CCB in improving heart failure outcomes.
For patients with chronic kidney disease (regardless of race), treatment should include an ACEI or ARB as these agents improve kidney function.
Agents approved by JNC8 for hypertension treatment:
|
Agent
|
Initial dose in mg
|
Target dose in mg
|
|
Captopril
|
50
|
150-200 in 2 doses
|
|
Enalpril
|
5
|
20 in 1-2 doses
|
|
Lisinopril
|
10
|
40 in 1 dose
|
|
eprosartan
|
400
|
600-800 in 1-2 doses
|
|
Candesartan
|
4
|
12-32 in 1 dose
|
|
Losartan
|
50
|
100 in 1-2 doses
|
|
Valsartan
|
40-80
|
160-320 in 1 dose
|
|
irbesartan
|
75
|
300 in 1 dose
|
|
Amlodipine
|
2.5
|
10 in 1dose
|
|
Diltiazem extended release
|
120-180
|
360 in 1 dose
|
|
Nifendipine
|
10
|
20 in 1-2 dose
|
|
Bendroflumethiazide
|
50
|
100 in 1 dose
|
|
Chlorthalidone
|
12.5
|
12.5 -25 in 1 dose
|
|
Hydrochlorothiazide
|
12.5-25
|
25-100 in 1-2 dose
|
|
Indapamide
|
1.25
|
1.25-2.5 in 1 dose
|
Our goal is to maintain blood pressure goals according to age; ensuring patient adherence to treatment and to lifestyle measure ( low sodium diet, weight control, avoid smoking and exercise) is important to achieve your goal. if goal can be achieved with one agent we can increase the dose to the maximum and then add another agent from another class (thiazide-type diuretic, CCB, ACEI, or ARB). If goal is still not reached with 2 drugs with maximum doses we can add a third agent. Do not use an ACEI and an ARB together in the same patient. If blood pressure goal is still not achieved after using 3 agents, antihypertensive drugs from other classes can be used (eg, β-blocker, aldosterone antagonist, or others)