Medications
Dozens of anti-hypertensive drugs are available. Most fall into the following categories:
- Diuretics, which cause the body to excrete water and salt. This is the standard agent for most people with hypertension.
- Beta-blockers, which block the effects of adrenaline, thus easing the heart's pumping action and widening blood vessels.
- Angiotensin converting enzyme (ACE) inhibitors, which reduce the production of angiotensin, a chemical that causes arteries to constrict.
- Vasodilators, which expand blood vessels.
- Calcium-channel blockers (CCBs), which help decrease the contractions of the heart and widen blood vessels.
- Angiotensin-receptor blockers (ARBs), which are newer agents that act on angiotensin.
In about half of patients a single-drug regimen can control mild to moderate hypertension. More severe hypertension often requires a combination of two or more drugs. Each may have specific benefits depending, but their effects vary depending on the individual patient.
Effects of Specific Anti-Hypertensives in Various Patient Populations*
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Patient Groups
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Diuretics
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ACE Inhibitors
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Beta Blockers
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Angiotensin-receptor blockers (ARBs)
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Calcium Channel Blockers (CCBs)
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Most Patients without Complicating Conditions
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Drug of choice for most patients. Inexpensive and effective. May be more effective in general than other drugs for lowering rates of heart failure stroke, angina. (2002 studies)
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Drug of choice in patients with diabetes or congestive heart failure. In some studies, better than diuretics for protection of blood vessels.
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Also good general first choice. Reduces risk of heart disease, stroke, and over all deaths from heart disease. (Use cautiously in people with lung disease or congestive heart failure).
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Evidence accumulating that they offer many of the same advantages as ACE inhibitors for patients who cannot tolerate ACE inhibitors.
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No better than other drugs in preventing heart attack or death from heart disease, except possibly for stroke (although this is not clear). Less effective than others for reducing risk of heart disease, heart failure or overall mortality.
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For Elderly Adults
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Drug of choice for most elderly patients. May protect against dementia and fractures. Lower their risk for heart attack, stroke, and heart failure compared to other drugs.
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Comparative studies with diuretics are mixed. May achieve fewer heart attacks in elderly Caucasian male. (2003 study) May also improve muscle strength in older individuals.
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Less effective and has more side effects than diuretics in this group.
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Not enough evidence.
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See comments above. Of note, however some of the newer CCBs may prove to be effective, safe, and have nerve-protecting properties that may be particularly useful in older people.
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African Americans
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Best choice.
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Not usually recommended as monotherapy, although may be effective in combination with diuretic or calcium channel blocker. Recommended for patients with diabetes or kidney disease.
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Not usually recommended as monotherapy, although may be effective in combination with diuretic. Recommended for patients with diabetes or kidney disease, or heart disease.
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Not recommended for first-line treatment. If other treatments do not work, may be used in combination with diuretic.
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Along with diuretics, CCBs have shown greater blood pressure lowering efficacy for African Americans than other drug classes. May be used in combination with ACE inhibitor.
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History of Heart Attack
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Lowers risk for progression to heart failure, second heart attack and death.
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Prevents second heart attack and death in these patients.
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Diabetes
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Has effects on blood sugar that might make this a worse choice than others.
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First choice. Protects against kidney disease. May not prevent progression of existing kidney disease in type 2 patients, although they do in type 1 diabetes.
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Very effective (although expensive.) May help prevent kidney disease and progression in both type 1 and 2 diabetes. May be first choice for preventing kidney failure in type 2 diabetics with kidney disease.
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Heart Failure
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Useful in these patients.
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First choice. May improve heart and lung muscle function
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Useful in these patients.
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* It should be noted that many people with hypertension require more than one kind of drug.
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Side Effects and Problems in Compliance
One of the most difficult issues that hypertensive patients face, particularly those with primary hypertension, is that the treatment may make them feel worse than the disease, which is almost always without symptoms. Patients face a life-long prospect of taking drugs with unpleasant side effects, reducing their salt intake, exercising, and watching their diet. Whatever the difficulties, compliance with a drug and lifestyle program is worth the effort and the cost. It is very important, in any case, to rigorously maintain a drug regimen.
Withdrawal from Anti-Hypertensive Medications
Patients whose blood pressure has been well-controlled and who are able to maintain a healthy life style may choose to withdraw from hypertensive medications. They should do so in a step-down manner (gradual reduction) and be monitored regularly. Stopping too quickly can have adverse effects, including serious effects on the heart. The highest success rates are more likely in those who lose weight and reduce sodium intake, in patients who have been treated with a single drug, and in those who have maintained lower systolic blood pressure during treatment. People over 75 years old may have more trouble than younger adults in maintaining normal blood pressure after withdrawal.
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