285
Treatment of Resistant Hypertension in the General
Population
Triple Therapy
For hypertensive patients requiring a triple therapy, the European Society of
Hypertension (ESH) and the European Society of Cardiology (ESC) recommenda-
tion of 2013 indicates that the choice should be made between four classes of anti-
hypertensive drugs: RAS inhibitors (ACEIs and ARBs), BBs, CCBs, and thiazide
diuretics [ 6 ]. However, in the past decade, BBs have been slightly “downgraded,”
after the publication of a meta-analysis [ 7 ] which revealed the association of these
drugs with a 16% higher stroke rate, as compared to the other agents [ 8 ]. Therefore,
other expert societies, including the British Hypertension Society [ 9 ], American
Heart Association [ 10 ], and French Society of Arterial Hypertension [ 11 ], suggest
that the triple combination should consist of ACEI/ARB + CCB + diuretic (the
“ACD regimen”), although there are no RCTs to support this suggestion.
Table 18.1 (continued)
Type of drug
Other indications
besides
hypertension
Additional
benefits Caution
Combined
use
BBs
Heart failure
(bisoprolol,
carvedilol, and
metoprolol)
Angina
Post-AMI
Reduction of
heart rate
Risk of bradycardia
Do not use with non-DHP
CCBs
ACEIs
ARBs
Diuretics
DHP
CCBs
Others
Centrally
acting
alpha-
agonists
Reduce moxonidine dose
if GFR <30 ml/
min/1.73 m^2
Diuretics
Alpha-
blockers
Prostatic
hypertrophy
Orthostatic hypotension BBs
Diuretics
Direct
vasodilators
Salt and water retention
Tachycardia
BBs
Diuretics
NSAIDs nonsteroidal anti-inflammatory drugs, ARBs angiotensin receptor blockers, COX2 cyclo-
oxygenase 2, DHP dihydropyridines, CKD chronic kidney disease, AMI acute myocardial infarc-
tion, ACEIs angiotensin-converting enzyme inhibitors, RAS renin-angiotensin system
18 Treatment of Hypertension in Light of the New Guidelines: Pharmacologic...