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Viera AJ The new normal blood pressure: what are the implications for family medicine J Am Board Fam Med 2007 Jan Feb;20(1):45 51 [PMID: 17204734] Whelton PK et al Strategies for improvement of awareness, treatment and control of hypertension: results of a panel discussion J Hum Hypertens 2004 Aug;18(8):563 5 [PMID: 15116145]

There are now many classes of potentially antihypertensive drugs of which five (diuretics, -blockers, ACE inhibitors, calcium channel blockers, and ARBs) are suitable for initial therapy based on efficacy and tolerability A number of considerations enter into the selection of the initial regimen for a given patient These include the weight of evidence for beneficial effects on clinical outcomes, the safety and tolerability of the drug, its cost, demographic differences in response, concomitant medical conditions, and lifestyle issues The specific classes of antihypertensive medications are discussed below, and guidelines for the choice of initial medications are offered

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Thiazide diuretics (Table 11 6) are the antihypertensives that have been most extensively studied and most consistently effective in clinical trials They lower blood pressure initially by decreasing plasma volume (by suppressing tubular reabsorption of sodium, thus increasing the excretion of sodium and water) and cardiac output, but during long-term therapy their major hemodynamic effect is reduction of peripheral vascular resistance Most of the antihypertensive effect of these agents is achieved at lower dosages than used previously (typically, 125 or 25 mg of hydrochlorothiazide or equivalent), but their biochemical and metabolic effects are dose related During longterm therapy, hydrochlorothiazide may be administered every other day with undiminished efficacy The loop diuretics (such as furosemide) may lead to electrolyte and volume depletion more readily than the thiazides and have short durations of action; therefore, loop diuretics should not be used in hypertension except in the presence of renal dysfunction (serum creatinine above 25 mg/dL) Relative to the -blockers and the ACE inhibitors, diuretics are more potent in blacks, older individuals, the obese, and other subgroups with increased plasma volume or low plasma renin activity Interestingly, they are relatively more effective in smokers than in nonsmokers Long-term thiazide administration also mitigates the loss of bone mineral content in older women at risk for osteoporosis Overall, diuretics administered alone control blood pressure in 50% of patients with mild to moderate hypertension and can be used effectively in combination with all other agents They are also useful for lowering isolated or predominantly systolic hypertension The adverse effects of diuretics relate primarily to the metabolic changes listed in Table 11 6 Impotence, skin rashes, and photosensitivity are less frequent Hypokalemia has been a concern but is

Birns J et al Blood pressure reduction for vascular risk: is there a price to be paid Stroke 2005 Jun;36(6):1308 13 [PMID: 15860749] Chobanian AV Prehypertension revisited Hypertension 2006 Nov;48(5):812 4 [PMID: 16982962] Drukteinis JS et al Cardiac and systemic hemodynamic characteristics of hypertension and prehypertension in adolescents and young adults: the Strong Heart Study Circulation 2007 Jan 16;115(2):221 7 [PMID: 17210838] Giles TD Blood pressure goals for hypertension guidelines: what is wrong with optimal J Clin Hypertens (Greenwich) 2006 Dec;8(12):835 9 [PMID: 17170608] Julius S et al; Trial of Preventing Hypertension (TROPHY) Study Investigators Feasibility of treating prehypertension with an angiotensin-receptor blocker N Engl J Med 2006 Apr 20;354(16):1685 97 [PMID: 16537662] Sever PS et al; ASCOT Investigators Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial Lancet 2003 Apr 5;361(9364):1149 58 [PMID: 12686036] Sever P et al ASCOT Steering Committee Members Potential synergy between lipid-lowering and blood-pressure-lowering in the Anglo-Scandinavian Cardiac Outcomes Trial Eur Heart J 2006 Dec;27(24):2982 8 [PMID: 17145722] Turnbull F et al; Blood Pressure Lowering Treatment Trialists Collaboration Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials Arch Intern Med 2005 Jun 27;165 (12):1410 9 [PMID: 15983291]

Initial Doses 125 or 25 mg once daily 125 or 25 mg once daily 125 or 25 mg once daily 25 mg once daily

Cost per Unit $008/ 25 mg $023/ 25 mg $148/5 mg $083/ 25 mg $016/ 40 mg $037/ 25 mg $052/1 mg $070/ 10 mg $046/ 25 mg $057/5 mg $378/ 25 mg $036

Adverse Effects K+, Mg2+, Ca2+, Na+, uric acid, glucose, LDL cholesterol, triglycerides; rash, erectile dysfunction

To save time in transferring between screens when you call up a transaction, you can utilize the shortcut commands in Table 1-1 The following function keys allow for additional shortcuts:

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