0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:13
764 Hypertension➣Limit alcohol intake (≤2 drinks/d for men;≤1 drink/day for
women and lighter-weight persons)
➣Maintain adequate potassium (∼90 mmol/d), calcium and mag-
nesium intake
➣Stop smoking
specific therapy
■Initial single-drug therapy: six agent classes recommended (includ-
ing compelling indications for preferential selection of specific class
if not specifically contraindicated):
➣Diuretics, usually thiazides (heart failure – loop diuretics, isolated
systolic hypertension of the elderly – thiazides; high coronary
disease risk, diabetes, recurrent stroke prevention)
➣Beta-blockers (heart failure, post-myocardial infarction, high
coronary disease risk, diabetes)
➣ACE inhibitors (heart failure, post-myocardial infarction, dia-
betes, chronic kidney disease, recurrent stroke prevention)
➣Calcium channel blockers (possibly preferred in blacks and
elderly; high coronary disease risk, diabetes)
➣Angiotensin II receptor blockers (heart failure, diabetes, chronic
kidney disease)
➣Aldosterone antagonist (heart failure, post-myocardial infarc-
tion)
■Second-line agents:
➣Alpha-adrenoreceptor antagonists (ALLHAT discontinued due
to increased CHF and stroke in patients treated with doxazosin;
may consider in men with prostatism)
➣Central sympatholytic agents (i.e., clonidine, methyldopa)
➣Arteriolar vasodilators (i.e., hydralazine, minoxidil)
➣Peripheral sympatholytic agents (i.e., reserspine)
Indications for Treatment
■Selection of therapy based on JNC classification and presence of
compelling indications, as above
Treatment Options
■Initiate therapy at low dose unless severe HTN.
■If the first-line therapy does not meet goals, consider increasing dose
or adding low dose of a complementary agent.
■If no discernable effect of agent at reasonable dose, consider switch-
ing to another agent.
■Multi-drug regimens are often necessary, especially in patients with
diabetes or higher SBP.