Antihypertensive Drugs: Which Drug for Which Condition

Treatment Flowchart (Uncomplicated Hypertension)

1. Uncomplicated / Primary Hypertension

Beta-blockers are no longer recommended as first-line for uncomplicated HTN - head-to-head trials show inferior CVD protection, especially for stroke prevention compared to the four classes above.

• Dual therapy: Diuretic OR CCB + ACEi or ARB
• Triple therapy: Diuretic + CCB + ACEi or ARB
• Resistant HTN: Add mineralocorticoid receptor antagonist (MRA) like spironolactone, alpha-blocker, or vasodilator

2. Condition-Specific Drug Choices (Compelling Indications)

Heart Failure (HFrEF)

• ACEi or ARB - cornerstone; reduces mortality
• Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) - proven mortality benefit
• MRA (spironolactone, eplerenone) - reduces mortality and hospitalizations
• SGLT2 inhibitors - especially if diabetes coexists (empagliflozin, dapagliflozin)
• Loop diuretics (furosemide) - for volume overload/congestion
• Non-DHP CCBs (diltiazem, verapamil) are CONTRAINDICATED in HFrEF

Post-Myocardial Infarction (Post-MI)

• Beta-blockers - first-line (metoprolol, carvedilol); reduce reinfarction and mortality
• ACEi or ARB - especially if EF is reduced
• MRA - if EF reduced and no significant renal impairment or hyperkalemia
• Avoid non-DHP CCBs if LV dysfunction is present

Angina / Ischemic Heart Disease

• Beta-blockers - first choice for stable angina (anti-ischemic)
• CCB (both DHP and non-DHP) - alternative or add-on for angina
• ACEi - reduce cardiovascular events in established IHD
• Long-acting nitrates - add-on for symptom control

Chronic Kidney Disease (CKD) / Proteinuria

• ACEi or ARB - primary agents; reduce intraglomerular pressure via efferent arteriolar dilation, slow proteinuria progression. Especially important with proteinuria and advanced CKD
• Diuretics - loop diuretics (furosemide) when eGFR <30 mL/min/1.73m² (thiazides less effective at low eGFR; however, chlorthalidone showed benefit even in stage 4 CKD in a recent RCT)
• CCBs - safe add-on but dilate afferent arteriole; use in combination with ACEi/ARB
• Monitor potassium carefully with ACEi/ARB + CKD

Diabetes Mellitus

• ACEi or ARB - preferred (renal protection, reduce microalbuminuria)
• SGLT2 inhibitors - now strongly recommended for cardio-renal protection beyond BP lowering
• CCBs - good add-on; metabolically neutral
• Thiazides - use with caution (slight dyslipidemia and dysglycemia risk, but still effective)
• Beta-blockers - can mask hypoglycemia symptoms; use if other indications (e.g., post-MI, HF)

Stroke Prevention / Cerebrovascular Disease

• CCBs - particularly effective for stroke prevention (superior to beta-blockers)
• ACEi or ARB - reduce recurrent stroke risk
• Thiazide diuretics - also effective for stroke prevention
• Target: SBP/DBP <130/80 mmHg

Isolated Systolic Hypertension (Elderly)

• Thiazide diuretics or CCBs - first choice; proven in large trials
• Start with lower doses; titrate gradually
• ACEi or ARB - also appropriate

Black / African-American Patients

• Thiazide diuretics + CCBs preferred (ACEi/ARBs less effective as monotherapy in this population)
• Combination therapy is usually needed
• ACEi/ARBs have higher rates of angioedema in Black patients

Hypertension in Pregnancy

• Labetalol (oral) - first-line
• Methyldopa - safe, traditional choice
• Nifedipine (oral) - alternative
• ACEi, ARBs, direct renin inhibitors are CONTRAINDICATED (teratogenic)

Hypertensive Emergency (IV Agents)

• Labetalol IV - versatile; safe in most emergencies
• Nicardipine IV - good for most hypertensive emergencies, including peri-operative
• Sodium nitroprusside IV - severe/refractory emergencies (watch for cyanide toxicity)
• Hydralazine IV - used in pregnancy-related emergencies
• Esmolol IV - aortic dissection, hypertensive crises with tachycardia

Pheochromocytoma

• Alpha-blockers first (phenoxybenzamine or doxazosin) - always before beta-blockers
• Beta-blockers added AFTER alpha-blockade - to control tachycardia (never give beta-blocker alone - can cause paradoxical hypertension)

Primary Aldosteronism (Conn's Syndrome)

• Spironolactone or eplerenone (MRAs) - first-line
• Also effective: amiloride

Benign Prostatic Hypertrophy (BPH) + HTN

• Alpha-1 blockers (doxazosin, terazosin) - treat both BPH and HTN simultaneously

Aortic Dissection

• Beta-blockers IV (labetalol, esmolol) - reduce HR and BP
• Sodium nitroprusside or nicardipine - if BP not controlled, always WITH beta-blockade

3. Quick Reference Summary Table