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Abstract
There is no uniform agreement as to which antihypertensive drugs should be given for initial therapy. All of the antihypertensive
agents are roughly equally effective, producing a good antihypertensive response in 30 to 50 percent of cases. Thus, in uncom-
plicated cases, the choice of an antihypertensive drug is not generally made on the basis of efficacy. There is, however, wide
inter-patient variability as many patients will respond well to one drug but not to another. There are also some predictable differ-
ences, such as black patients generally responding better to monotherapy with a thiazide diuretic or calcium channel blockers
(CCBs), and relatively poorly to ACE (angiotensin-converting enzyme) inhibitors or beta blockers.
SA Fam Pract 2007;49(8): 27-30
Beta blockers
A beta blocker without intrinsic sympa-
thomimetic activity should be given af-
ter an acute myocardial infarction and to
stable patients with heart failure or as- sive patients. Like beta blockers, they the next dose. This is of concern, since
ymptomatic left ventricular dysfunction can be given for rate control in patients a greater daily blood pressure load and
(beginning with very low doses to min- with atrial fibrillation or for control of an- early morning abrupt elevation in blood
imise the risk and degree of initial wors- gina. pressure can increase cardiovascular
ening of myocardial function). The use risk.
of beta blockers in these settings is in Other specific settings Giving half the dose twice a day pro-
addition to the recommendations for Beyond these indications, a number duces a lesser peak effect but a more
ACE inhibitors in these disorders. of specific recommendations can be sustained response; however, adher-
Beta blockers are also given for rate made for drugs with favourable effects ence may be reduced. Drugs that are
control in patients with atrial fibrillation, in various settings. As an example, an longer-acting, either by inherent proper-
for control of angina, and for symptom alpha blocker may be preferred in older ties or special delivery systems, are the
control in a number of other disorders. men with symptoms of prostatism. better choice. It is prudent, however, to
Compared to other antihypertensive check the blood pressure in the morning
drugs, during the primary treatment of Drug dosing and drug frequency prior to the next dose whenever a once
hypertension, beta blockers may be as- The steepest part of the dose response daily regimen is used.
sociated with a small absolute increase curve is frequently seen at lower doses:
in the stroke rate (particularly among Good responders generally respond to Combination therapy
smokers) and perhaps, with atenolol, a low doses with few side effects, while Administering two drugs as initial thera-
small increase in mortality. Thus, in the higher doses produce more side effects py should be considered in patients with
absence of a specific indication for their often with little further reduction in blood blood pressure that is more than 20/10
use, beta blockers should not be used pressure. mmHg above goal blood pressure. This
as primary therapy for hypertension. The theoretical therapeutic and toxic strategy may increase the likelihood that
effect curves of antihypertensive agents target blood pressure is achieved in a
Diuretics reasonable time period, but should be
vary based upon the administered dose.
A thiazide diuretic should be prescribed used cautiously in patients at increased
The theoretical effects of a single drug
in the absence of an indication for any risk for orthostatic hypotension (such as
given at two different doses (10 and 20
other specific drug(s) or when goal diabetics and the elderly).
units) are shown in figure 3. At a dose
blood pressure has not been attained. In patients with mild hypertension, the
of 10 units, the antihypertensive agent
Diuretics should also be given for flu- first-line agent will normalise the blood
id control in patients with heart failure has a minimal toxic effect (A) and a
pressure in up to 50 percent of patients.
or nephrotic syndrome; these settings moderate therapeutic effect (A). Dou-
A second drug should be considered if
usually require loop diuretics. In addi- bling the dose, however, is associated there is a suboptimal response to initial
tion, an aldosterone antagonist is indi- with substantial toxic effects (B) but little therapy. The rationale behind a combi-
cated in patients with advanced heart increase in therapeutic efficacy (B).5 nation regimen is that early addition of
failure who have relatively preserved re- The issue of dose frequency relates a second drug may be: (1) as or more
nal function and, in patients with less se- to the absence of 24 hour efficacy with effective, since many responders to a
vere disease, for the treatment of hypo- certain long-acting drugs such as the given drug do so at relatively low doses;
kalaemia. angiotensin-converting enzyme inhibitor and (2) associated with less toxicity.
enalapril. Once daily dosing gives a Most drug combinations, using
Calcium channel blockers greater peak response, but the blood agents that act by different mecha-
There are no absolute indications for pressure tends to return toward base- nisms, tend to have an additive effect.
calcium channel blockers in hyperten- line in the early morning hours prior to Examples include an ACE inhibitor with
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