Selection of
Antihypertensive Drug
Hypertension classification
BP Classification
Normal
Systolic BP,
mm Hg
Diastolic BP,
mm Hg
<120
and
< 80
Pre hypertension
120 – 139
or
80 – 89
Stage 1
hypertension
140 – 159
or
90 – 99
Stage 2
hypertension
≥ 160
or
≥ 100
Risk Stratification
Blood
Pressure
(mm Hg)
Other risk and
disease
history
Stage 1
Stage 2
Stage 3
(severe
hypertension)
SBP 140-159 or
DBP 90-99
SBP 160-179 or
DBP 100-109
SBP ≥ 180 or
DBP ≥ 110
Low risk
Medium risk
High risk
I
No other risk
factors
II
1-2 risk factors
Medium risk
Medium risk
Very high risk
III
3 or more risk
factors or TOD
or diabetes
High risk
High risk
Very high risk
IV
ACC
Very high risk
Very high risk
Very high risk
Clinical trial and guideline basis for compelling
indications for individual drug classes
Compelling
Indication
Diuretic
Heart failure
●
BB ACEI ARB CCB ALD ANT
●
●
●
●
●
Postmyocardi
al infarction
High coronary
disease risk
●
●
●
Diabetes
●
●
●
●
●
●
Chronic
kidney
disease
Recurrent
stroke
prevention
●
●
●
●
●
●
Low risk
-
3 months
Medium risk
-
2 – 3 months
High & very high risk -
immediate
-Diuretics
e.g.:- Hydrochlorothiazide 12.5 – 50 mg od
- - blockers
eg:- Atenolol 25 – 100 mg od
propranolol long acting 60 – 180 mg od
Calcium channel blockers:
Amlodipine 2.5 – 10 mg od
Diltiazem XR – 180 – 420 mg od
Verapamil long acting 120 – 480 mg od –bd
ACE Inhibitors:
Enalapril 5 -40 mg od – bd
Ramipril 2.5 – 20mg od
ARBs:
Losartan – 25 – 100 mg od – bd
When to add 2nd drug?
- Single drug fails to active BP goal (BP is 20 / 10
mm Hg above goal)
- Most stage 2 hypertension
Thiazide – type diuretic + ACE, ARB, BB, CCB
1. Enalapril 5 mg + Hydrochlorothiazide 12.5 mg.
2. Losartan 50mg + Hydrochlorothiazide 12.5 mg.
3. Propranolol LA + Hydrochlorothiazide 40 / 25 mg.
4. Amlodipine + Hydrochlorothiazide 5/12.5 mg.
When to add 3rd drug?
What to add?
ACE + CCB + Diuretic
Enalapril 5 + Amlodipine 5 + Hydrochlorothiazide 12.5
mg
BB + CCB + Diuretic
Atenolol 50 + Amlodipine 5+
Hydrochlorothiazide12.5mg
Resistant :
Add either  - blocker prazosin 2 – 20mg bd –tds
or Doxazosin 1 – 16 mg od
Spironolactone – 25 mg
Other diuretic – Metolazone 2.5 mg
– indapamide 1.25 – 2.5 mg
- Acute myocardial ischemia
 Nitroglycerin –5 to 10 µg / min as IV infusion
  - blockers –ESMOLOL 250 to 500 µg / kg / min for I
minute, then 50 to 100 µg / kg for 4 minutes
 ACEI (if available) – ENALAPRILAT 1.25 to 5 mg q6
hour IV
-CHF with pulmonary edema
 Nitroglycerin –5 to10 µg / min as IV infusion
 Frusemide
 Morphine
- Acute aortic dissection
 Nitroprusside IV plus  - blockers esmolol
1. Dose is 5 to 10 µg / min as IV infusion
2. Dose is 250 to 500 µg / kg / min for I minute, then 50 to
100 µg / kg for 4 minutes.
 Alternative – Trimethaphan plus  - blocker
- Cerebral vascular accident:
 Nitroprusside - 5 to10 µg / min as IV infusion
 Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2
mg / min infusion
 Nimodipine
- Pheocheromocytoma
 Phentolamine 5-15 mg IV
 Nitroprusside –5 to 10µg / min as IV infusion
 Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2
mg / min infusion
- Hypertensive encephalopathy
 Nitroprusside –5 to 10µg / min as IV infusion
 Trimethaphan
  - blockers - 250 to 500µg / kg / min for I minute, then 50
to 100µg / kg for 4 maintained
Hypertensive encephalopathy
 Hydralazine- 10-50 mg IV / IM
 Labetalol – 20-80mg IV bolus every 10 minutes or 0.5
to 2 mg / min infusion
 Magnesium IV
Class
Drug (Trade Name)
Thiazide
diuretics
chlorothiazide
chlorthalidone
hydrochlorothiazide
polythiazide
indapamide
metolazone
metolazone
Loop
diuretics
Usual Dose
Range in
mg/Day
Usual Daily
mg/Day
Frequency*
125–500
12.5–25
12.5–50
2–4
1.25–2.5
0.5–1.0
2.5–5
1–2
1
1
1
1
1
1
bumetanide
furosemide
torsemide
0.5–2
20–80
2.5–10
2
2
1
Potassiumsparing
diuretics
amiloride
triamterene
5–10
50–100
1–2
1–2
Aldosterone
receptor
blockers
eplerenone
Spironolactone
50–100
25–50
1
1
Class
Drug (Trade Name)
Usual Dose Usual Daily
Range in
mg/Day
mg/Day
Frequency*
BBs
Atenolol
Propranolol
propranolol long-acting
25–100
40-160
60-180
1
2
1
Combined
alpha- and
BBs
Carvedilol
labetalol
12.5–50
200–800
2
2
ACEIs
enalapril
ramipril
5-40
2.5-20
1-2
1
Angiotensin II
antagonists
losartan
25-100
1-2
CCBs—
nondihydropyr
idines
diltiazem extended release
diltiazem extended release
verapamil immediate release
verapamil long acting
Verapamil
180-420
120-540
80-320
120-480
120-360
1
1
2
1-2
1
Class
Drug (Trade Name)
CCBsdihydropyridi
nes
amlodipine
nifedipine long-acting
Alpha-1
blockers
doxazosin
prazosin
terazosin
Central alpha2 agonists
and other
centrally
acting drugs
clonidine
clonidine patch
methyldopa
reserpine
guanfacine
Direct
vasodilators
hydralazine
minoxidil
Usual Dose
Range in
mg/Day
Usual Daily
mg/Day
Frequency*
2.5-10
30-60
1
1
1-16
2-20
1-20
1
2-3
1-2
0.1-0.8
0.1-0.3
250-1000
0.1-0.25
0.5-2
2
1 wkly
2
1
1
25-100
2.5-80
2
1-2