The AHA Guidelines and Scientifi c Statements Handbook
Table 11.8 JNC 7 Clinical Trial and Guideline basis for compelling indications for individual drug classes
Recommended drugsCompelling Indication* Diuretic BB ACEI ARB CCB Aldo Ant Clinical Trial Basis†
Heart failure • • • • • ACC/AHA Heart Failure Guideline, MERIT-HF,
COPERNICUS, CIBIS, SOLVD, AIRE,
TRACE, ValHEFT, RALES, CHARM
Post-myocardial infarction • • • ACC/AHA Post-MI Guideline, BHAT, SAVE,
Capricorn, EPHESUS
High coronary disease risk • • • • ALLHAT, HOPE, ANBP2, LIFE, CONVINCE,
EUROPA, INVEST
Diabetes • • • • • NKF-ADA Guideline, UKPDS, ALLHAT
Chronic kidney disease • • NKF Guideline, Captopril Trial, RENAAL,
IDNT, REIN, AASK
Recurrent stroke prevention • • PROGRESS
BB indicates β-blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; Aldo Ant, aldosterone
antagonist.
- Compelling indications for antihypertensive drugs are based on benefi ts from outcome studies or existing clinical guidelines; the compelling indication is managed
in parallel with the BP.
† Conditions for which clinical trials demonstrate benefi t of specifi c classes of antihypertensive drugs used as part of an antihypertensive regimen to achieve BP goal
to test outcomes. For references, see Chobanian et al. [1]. Reproduced, with permission, from Chabanian et al. [1]
Special considerations
CAD and stable angina
Patients with hypertension and chronic stable angina
should be treated with a regimen that includes a β-
blocker in patients with a history of prior MI, an
ACE inhibitor or ARB if there is diabetes mellitus
and/or LV systolic dysfunction, and a thiazide
diuretic (Class I; Level of Evidence A). The combina-
tion of a β-blocker, ACE inhibitor or ARB, and a
thiazide diuretic should also be considered in the
absence of a prior MI, diabetes mellitus, or LV sys-
tolic dysfunction (Class IIa; Level of Evidence B).
If β-blockers are contraindicated or produce
intolerable side effects, a non-dihydropyridine CCB
(such as diltiazem or verapamil) can be substituted,
but not if there is LV dysfunction (Class IIa; Level of
Evidence B). If either the angina or the hypertension
remains uncontrolled, a long-acting dihydropyri-
dine CCB can be added to the basic regimen of β-
blocker, ACE inhibitor, and thiazide diuretic. The
combination of a β-blocker and either of the non-
dihydropyridine CCBs (diltiazem or verapamil)
should be used with caution in patients with symp-
tomatic CAD and hypertension because of the
increased risk of signifi cant bradyarrhythmias and
HF (Class IIa; Level of Evidence B).
The target BP is <130/80 mm Hg. If ventricu-
lar dysfunction is present, consideration should
be given to lowering the BP even further, to
<120/80 mm Hg. In patients with CAD, the BP
should be lowered slowly, and caution is advised in
inducing falls of DBP below 60 mm Hg. In older
hypertensive individuals with wide pulse pressures,
lowering SBP may cause very low DBP values
(<60 mm Hg). This should alert the clinician to
assess carefully any untoward signs or symptoms,
especially those due to myocardial ischemia (Class
IIa; Level of Evidence B).
There are no special contraindications in hyper-
tensive patients to the use of nitrates, antiplatelet or
anticoagulant drugs, or lipid-lowering agents for the
management of angina and the prevention of coro-
nary events, except that in uncontrolled severe
hypertension in patients who are taking antiplatelet
or anticoagulant drugs, BP should be lowered
without delay to reduce the risk of hemorrhagic
stroke (Class IIa; Level of Evidence C).