Selection of

Antihypertensive Drug

BP Classification Systolic BP,

mm Hg

Diastolic BP,

mm Hg

Normal <120 and < 80

Pre hypertension 120 – 139 or 80 – 89

Stage 1

hypertension

140 – 159 or 90 – 99

Stage 2

hypertension

≥ 160 or ≥ 100

Hypertension classification

Blood Pressure (mm Hg)

Other risk and disease history

Stage 1 Stage 2Stage 3 (severe hypertension)

SBP 140-159 or DBP 90-99

SBP 160-179 or DBP 100-109

SBP ≥ 180 or DBP ≥ 110

INo other risk factors

Low risk Medium risk High risk

II 1-2 risk factors Medium risk Medium risk Very high risk

III3 or more risk factors or TOD or diabetes

High risk High risk Very high risk

IV ACC Very high risk Very high risk Very high risk

Risk Stratification

Compelling Indication Diuretic BB ACEI ARB CCB ALD ANT

Heart failure ● ● ● ● ●

Postmyocardial infarction ● ● ●

High coronary disease risk ● ● ● ●

Diabetes ● ● ● ● ●

Chronic kidney disease

● ●

Recurrent stroke prevention

● ●

Clinical trial and guideline basis for compelling indications for individual drug classes

Low risk - 3 months

Medium risk - 2 – 3 months

High & very high risk - immediate

-Diuretics

e.g.:- Hydrochlorothiazide 12.5 – 50 mg od

- blockers

eg:- Atenolol 25 – 100 mg od

propranolol long acting 60 – 180 mg od

Calcium channel blockers:

Amlodipine 2.5 – 10 mg od

Diltiazem XR – 180 – 420 mg od

Verapamil long acting 120 – 480 mg od –bd

ACE Inhibitors:

Enalapril 5 -40 mg od – bd

Ramipril 2.5 – 20mg od

ARBs:

Losartan – 25 – 100 mg od – bd

When to add 2nd drug?

- Single drug fails to active BP goal (BP is 20 / 10 mm Hg above goal)

- Most stage 2 hypertension

Thiazide – type diuretic + ACE, ARB, BB, CCB

1.Enalapril 5 mg + Hydrochlorothiazide 12.5 mg.

2.Losartan 50mg + Hydrochlorothiazide 12.5 mg.

3.Propranolol LA + Hydrochlorothiazide 40 / 25 mg.

4.Amlodipine + Hydrochlorothiazide 5/12.5 mg.

When to add 3rd drug?

What to add?

ACE + CCB + Diuretic

Enalapril 5 + Amlodipine 5 + Hydrochlorothiazide 12.5 mg

BB + CCB + Diuretic

Atenolol 50 + Amlodipine 5+ Hydrochlorothiazide12.5mg

Resistant :

Add either - blocker prazosin 2 – 20mg bd –tds or Doxazosin 1 – 16 mg od

Spironolactone – 25 mg

Other diuretic – Metolazone 2.5 mg

– indapamide 1.25 – 2.5 mg

- Acute myocardial ischemia Nitroglycerin –5 to 10 µg / min as IV infusion

- blockers –ESMOLOL 250 to 500 µg / kg / min for I minute, then 50 to 100 µg / kg for 4 minutes

ACEI (if available) – ENALAPRILAT 1.25 to 5 mg q6 hour IV

-CHF with pulmonary edema Nitroglycerin –5 to10 µg / min as IV infusion

Frusemide

Morphine

- Acute aortic dissection

Nitroprusside IV plus - blockers esmolol

1. Dose is 5 to 10 µg / min as IV infusion

2. Dose is 250 to 500 µg / kg / min for I minute, then 50 to 100 µg / kg for 4 minutes.

Alternative – Trimethaphan plus - blocker

- Cerebral vascular accident: Nitroprusside - 5 to10 µg / min as IV infusion

Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion

Nimodipine

- Pheocheromocytoma Phentolamine 5-15 mg IV

Nitroprusside –5 to 10µg / min as IV infusion

Labetalol –20-80mg IV bolus every 10 minutes or 0.5 to 2 mg / min infusion

- Hypertensive encephalopathy

Nitroprusside –5 to 10µg / min as IV infusion

Trimethaphan

- blockers - 250 to 500µg / kg / min for I minute, then 50 to 100µg / kg for 4 maintained

Hypertensive encephalopathy

Hydralazine- 10-50 mg IV / IM

Labetalol – 20-80mg IV bolus every 10 minutes or 0.5

to 2 mg / min infusion

Magnesium IV

Class Drug (Trade Name) Usual Dose

Range in

mg/Day

Usual Daily

mg/Day

Frequency*

Thiazide diuretics

chlorothiazide

chlorthalidone

hydrochlorothiazide

polythiazide

indapamide

metolazone

metolazone

125–500

12.5–25

12.5–50

2–4

1.25–2.5

0.5–1.0

2.5–5

1–2

1

1

1

1

1

1

Loop

diuretics

bumetanide

furosemide

torsemide

0.5–2

20–80

2.5–10

2

2

1

Potassium-sparing diuretics

amiloride

triamterene

5–10

50–100

1–2

1–2

Aldosterone receptor blockers

eplerenone

Spironolactone

50–100

25–50

1

1

Class Drug (Trade Name) Usual Dose

Range in

mg/Day

Usual Daily

mg/Day

Frequency*

BBs Atenolol

Propranolol

propranolol long-acting

25–100

40-160

60-180

1

2

1

Combined

alpha- and

BBs

Carvedilol

labetalol

12.5–50

200–800

2

2

ACEIs enalapril

ramipril

5-40

2.5-20

1-2

1

Angiotensin II antagonists

losartan 25-100 1-2

CCBs—nondihydropyridines

diltiazem extended release

diltiazem extended release

verapamil immediate release

verapamil long acting

Verapamil

180-420

120-540

80-320

120-480

120-360

1

1

2

1-2

1

Class Drug (Trade Name) Usual Dose

Range in

mg/Day

Usual Daily

mg/Day

Frequency*

CCBs-dihydropyridines

amlodipine

nifedipine long-acting

2.5-10

30-60

1

1

Alpha-1

blockers

doxazosin

prazosin

terazosin

1-16

2-20

1-20

1

2-3

1-2

Central alpha-2 agonists and other

centrally acting drugs

clonidine

clonidine patch

methyldopa

reserpine

guanfacine

0.1-0.8

0.1-0.3

250-1000

0.1-0.25

0.5-2

2

1 wkly

2

1

1

Direct vasodilators

hydralazine

minoxidil

25-100

2.5-80

2

1-2