Resistant Hypertension in Chronic Kidney Disease

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...