Guidelines for selecting initial drug treatment of Hypertension

For adults of age 18 years & more, hypertension is systolic blood pressure >140 mmHg and/ or diastolic blood pressure >90 mmHg.

1. Diuretics

This group of drugs flushes excess sodium from the body, which reduces the amount of fluid in the blood and helps to lower your blood pressure. Examples Chlorothiazide, Chlorthalidone, etc.

Compelling indications:

• Heart failure 
• Elderly patients
• Systolic hypertension

Compelling contraindications:

• Gout

2. Beta-blockers (BB) 

This group of drugs helps the heart to beat slower and with less force. As a result, the heart pumps less blood through blood vessels, which can help to lower blood pressure. Examples Atenolol, Propranolol, etc.

Compelling indications:

• Angina 
• After MI 
• Tachyarrhythmia 

Possible indications: 

• Heart failure 
• Pregnancy

Compelling contraindications:

• Uncontrolled asthma and Chronic obstructive pulmonary disease (COPD) 
• Heart block ( second or third-degree atrioventricular block)

Possible contraindications:

• Athletes and physically active patients 
• Peripheral vascular disease

3. Angiotensin-converting enzyme (ACE) inhibitors:

Angiotensin-II is a hormone that narrows blood vessels, increasing blood pressure. ACE converts Angiotensin I to Angiotensin II. ACE inhibitors block this process, which stops the production of Angiotensin II, lowering blood pressure. Examples Lisinopril, Enalapril, etc.

Compelling indications:

• Heart failure
• LV dysfunction
• After MI
• Diabetic nephropathy

Possible indications:

• Chronic renal parenchymal disease

Compelling contraindications:

• Pregnancy
• Hyperkalemia
• Bilateral renal artery stenosis

4. Angiotensin receptor blockers (ARB)

This group of drugs blocks angiotensin II hormone from binding with receptors in the blood vessels. When angiotensin II is blocked, the blood vessels do not constrict or narrow, which can lower your blood pressure. Examples Losartan, Telmisartan, etc.

Compelling indications:

• ACE inhibitor cough
• Heart failure
• Diabetic nephropathy

Possible indications:

• Chronic renal parenchymal disease

Compelling contraindications:

• Pregnancy
• Bilateral renal artery stenosis
• Hyperkalemia

5. Calcium channel blockers (CCB)

This group of drugs keeps calcium from entering the muscle cells of the heart and blood vessels. This allows blood vessels to relax, which can lower blood pressure. Examples Amlodipine, Nifedipine, etc.

Compelling indications:

• Angina
• Elderly patients
• Systolic hypertension

Possible indications:

• Peripheral vascular disease

Compelling contraindications:

• Heart block ( second or third-degree atrioventricular block with verapamil or diltiazem)

Possible contraindications:

• Congestive heart failure ( Verapamil or diltiazem) 

References:

1. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jamenson J. Harrinson´ s manual of medicine. 2013.
2. Reid J. John Murtagh's General Practice (; John Murtagh and Jill Rosenblatt). 2015.
3. https://www.nhp.gov.in/disease/cardio-vascular/hypertension-high-blood-pressure