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Antihypertensive Drugs: Which Drug for Which Condition

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Drug Treatment Algorithm for Uncomplicated Hypertension

Beta-blockers are added at any step when there is a specific indication: heart failure, angina, post-MI, atrial fibrillation, or younger pregnant women.

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Compelling Indications Table (JNC 7 / ACC-AHA)

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Detailed Drug-by-Drug Breakdown

1. Thiazide/Thiazide-like Diuretics (e.g., Hydrochlorothiazide, Chlorthalidone)

• Indications: Uncomplicated HTN (first-line), heart failure, high CAD risk, diabetes, stroke prevention
• Mechanism: Inhibit Na-Cl cotransporter in distal convoluted tubule
• Side effects: Hypokalemia, hyponatremia, hyperuricemia, impaired glucose tolerance, dyslipidemia
• Note: Chlorthalidone preferred over HCTZ (longer duration, better CV outcomes)

2. Loop Diuretics (e.g., Furosemide)

• Indications: HTN with volume overload, heart failure with fluid retention, CKD with low GFR (<30)
• Mechanism: Inhibit Na-K-2Cl cotransporter in thick ascending limb
• Side effects: Hypokalemia, ototoxicity, fewer metabolic effects than thiazides

3. ACE Inhibitors (e.g., Ramipril, Lisinopril, Enalapril)

• Indications: Heart failure, post-MI, CKD (especially with proteinuria), diabetes, high CAD risk, stroke prevention
• Mechanism: Block conversion of angiotensin I to angiotensin II
• Side effects: Dry cough (10-15%), hyperkalemia, elevated creatinine, angioedema, teratogenic (avoid in pregnancy)

4. Angiotensin Receptor Blockers/ARBs (e.g., Losartan, Valsartan, Telmisartan)

• Indications: Same as ACEi - heart failure, CKD, diabetes; preferred when patient cannot tolerate ACEi (due to cough)
• Mechanism: Block angiotensin II at the AT1 receptor
• Side effects: Similar to ACEi but NO cough; also teratogenic (avoid in pregnancy)

5. Calcium Channel Blockers/CCBs

6. Beta-Blockers (e.g., Metoprolol, Carvedilol, Atenolol, Labetalol)

• Indications: HTN + heart failure (HFrEF), post-MI, angina, atrial fibrillation (rate control), hypertensive urgency in pregnancy (labetalol)
• Side effects: Reduced exercise tolerance, depression, bronchospasm (non-selective BB), impaired glucose masking
• Contraindication: Asthma/COPD (use cardioselective if essential), severe bradycardia, decompensated HF acutely

7. MRA - Mineralocorticoid Receptor Antagonists (e.g., Spironolactone, Eplerenone)

• Indications: Resistant hypertension (4th-line add-on), heart failure (HFrEF), post-MI with HF, primary hyperaldosteronism
• Side effects: Hyperkalemia, gynecomastia (spironolactone), menstrual irregularities

8. Alpha-Blockers (e.g., Doxazosin, Prazosin)

• Indications: HTN + benign prostatic hyperplasia (BPH), pheochromocytoma (phentolamine)
• Note: Not first-line for HTN alone due to increased CV events in ALLHAT trial

9. Central Alpha-2 Agonists (e.g., Methyldopa, Clonidine)

• Indications: Hypertension in pregnancy (methyldopa is drug of choice), resistant HTN
• Side effects: Sedation, dry mouth, rebound HTN on abrupt withdrawal (clonidine)

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Special Situations - Drug of Choice

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Hypertensive Emergency - Drug Guide

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Drugs to Avoid in Specific Conditions

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• Compelling Indications table (JNC 7 / ACC-AHA 2018) - checkmark grid across all 11 conditions vs 6 drug classes
• Full Drug Class Summary - mechanism, examples, side effects, and key indications for all 10 drug classes (thiazides through central agonists)

• Step-up Treatment Algorithm (dual → triple → resistant HTN)
• Special Clinical Situations (pregnancy, elderly, black patients, CKD, Raynaud's, etc.)
• Hypertensive Emergency IV agents by emergency type (with "Avoid" column)
• Drugs to Avoid table with reasons

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<div class="header"><h1>BP MEDICATIONS — QUICK REFERENCE CHART</h1><p>JNC 7 · ACC/AHA 2018 · Comprehensive Clinical Nephrology 7e · NKF Primer 8e</p></div>
<div class="section-title teal">COMPELLING INDICATIONS (JNC 7 / ACC-AHA 2018)</div>
<table id="ci"><thead><tr><th style="text-align:left">Condition</th><th>Diuretic<br>(Thiazide)</th><th>Beta-Blocker</th><th>ACE Inhibitor</th><th>ARB</th><th>CCB</th><th>MRA (Spiro)</th><th>Notes</th></tr></thead><tbody>
<tr><td class="td-label">Heart Failure (HFrEF)</td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td>Avoid verapamil / diltiazem</td></tr>
<tr><td class="td-label">Post-MI</td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td>Beta-blocker within 24 h</td></tr>
<tr><td class="td-label">High CAD Risk / Angina</td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td>CCB: prefer amlodipine</td></tr>
<tr><td class="td-label">Diabetes Mellitus</td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td>ACEi/ARB renoprotective</td></tr>
<tr><td class="td-label">CKD / Proteinuria</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>ACEi or ARB first-line</td></tr>
<tr><td class="td-label">Stroke Prevention (Recurrent)</td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>Thiazide + ACEi combo</td></tr>
<tr><td class="td-label">Atrial Fibrillation (Rate control)</td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>✔ non-DHP (diltiazem)</td><td><span class="dash">—</span></td><td>Avoid DHP CCBs alone</td></tr>
<tr><td class="td-label">Pregnancy</td><td><span class="dash">—</span></td><td>✔ Labetalol only</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>✔ Nifedipine SR</td><td><span class="dash">—</span></td><td>Methyldopa also safe</td></tr>
<tr><td class="td-label">BPH</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>Alpha-blocker (doxazosin)</td></tr>
<tr><td class="td-label">Phaeochromocytoma</td><td><span class="dash">—</span></td><td>✔ After alpha-block</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>Phentolamine FIRST, then BB</td></tr>
</tbody></table>
<div class="section-title green">DRUG CLASS SUMMARY — Mechanisms, Side Effects &amp; Key Indications</div>
<table id="dc"><thead><tr><th style="text-align:left">Drug Class</th><th>Examples</th><th>Mechanism</th><th>Side Effects</th><th style="text-align:left">Key Indications / Notes</th></tr></thead><tbody>
<tr><td class="td-label">Thiazide / Thiazide-like Diuretics</td><td>HCTZ, Chlorthalidone, Indapamide</td><td>Inhibit Na-Cl cotransporter (DCT)</td><td>Hypokalemia, hyperuricemia, hyperglycemia, dyslipidemia</td><td>First-line uncomplicated HTN; HF; CAD; stroke. Chlorthalidone preferred over HCTZ.</td></tr>
<tr><td class="td-label">Loop Diuretics</td><td>Furosemide, Bumetanide</td><td>Inhibit Na-K-2Cl cotransporter (thick ascending limb)</td><td>Hypokalemia, ototoxicity, dehydration</td><td>HTN + volume overload; HF; CKD with GFR &lt;30</td></tr>
<tr><td class="td-label">ACE Inhibitors</td><td>Ramipril, Lisinopril, Enalapril</td><td>Block Ang I→Ang II; bradykinin accumulation</td><td>Dry cough (10-15%), hyperkalemia, angioedema</td><td>HF, post-MI, CKD+proteinuria, diabetes, stroke. AVOID: pregnancy, bilateral RAS.</td></tr>
<tr><td class="td-label">ARBs</td><td>Losartan, Valsartan, Telmisartan</td><td>Block Ang II at AT1 receptor (no bradykinin)</td><td>Similar to ACEi — NO cough</td><td>Same as ACEi. Preferred when ACEi cough intolerable. AVOID: pregnancy, bilateral RAS.</td></tr>
<tr><td class="td-label">Dihydropyridine CCBs (DHP)</td><td>Amlodipine, Nifedipine SR, Felodipine</td><td>Block L-type Ca²⁺ → vasodilation</td><td>Peripheral edema, flushing, gingival hyperplasia</td><td>Uncomplicated HTN, elderly, angina, CKD, black patients, diabetes</td></tr>
<tr><td class="td-label">Non-DHP CCBs</td><td>Diltiazem, Verapamil</td><td>Block L-type Ca²⁺ + AV nodal depression</td><td>Bradycardia, AV block; verapamil: constipation</td><td>HTN + angina + AF rate control. AVOID: HFrEF, AV block, with beta-blockers.</td></tr>
<tr><td class="td-label">Beta-Blockers</td><td>Metoprolol, Carvedilol, Bisoprolol, Labetalol</td><td>Block β1 (±β2) adrenergic receptors</td><td>Fatigue, bradycardia, bronchospasm, masks hypoglycemia</td><td>HFrEF, post-MI, angina, AF, pregnancy (labetalol). AVOID: asthma, severe bradycardia.</td></tr>
<tr><td class="td-label">MRA / Spironolactone</td><td>Spironolactone, Eplerenone</td><td>Block aldosterone receptor</td><td>Hyperkalemia, gynecomastia, menstrual changes</td><td>Resistant HTN (4th-line); HFrEF; post-MI with HF; primary hyperaldosteronism</td></tr>
<tr><td class="td-label">Alpha-1 Blockers</td><td>Doxazosin, Prazosin, Phentolamine IV</td><td>Block α1 receptors → vasodilation</td><td>First-dose orthostatic hypotension</td><td>HTN + BPH; phaeochromocytoma (phentolamine FIRST). Not first-line alone.</td></tr>
<tr><td class="td-label">Central α2-Agonists</td><td>Methyldopa, Clonidine</td><td>Stimulate α2 in CNS → reduce sympathetic outflow</td><td>Sedation, dry mouth; rebound HTN (clonidine)</td><td>Methyldopa: drug of choice in pregnancy. Not 1st-line otherwise.</td></tr>
</tbody></table>
<hr class="page-break">
<div class="section-title amber">STEP-UP TREATMENT ALGORITHM (Uncomplicated HTN)</div>
<table id="algo"><thead><tr><th>Step</th><th>Regimen</th><th>Detail</th><th>When to Use</th></tr></thead><tbody>
<tr><td style="text-align:center;font-weight:bold">1</td><td class="td-label">Dual combination</td><td><strong>ACEi or ARB + CCB</strong> or <strong>Thiazide diuretic</strong></td><td>BP ≥140/90 mmHg (monotherapy if just above 140/90 or frail elderly)</td></tr>
<tr><td style="text-align:center;font-weight:bold">2</td><td class="td-label">Triple combination</td><td><strong>ACEi or ARB + CCB + Thiazide diuretic</strong></td><td>Dual combo insufficient to reach BP target</td></tr>
<tr><td style="text-align:center;font-weight:bold">3</td><td class="td-label">Resistant HTN</td><td>Triple combo + Spironolactone 25–50 mg OD (or alpha-blocker or beta-blocker)</td><td>BP uncontrolled on 3 drugs; refer to specialist</td></tr>
<tr class="algo-star"><td style="text-align:center;font-weight:bold">★</td><td class="td-label">Beta-blockers</td><td>Add at ANY step when specific indication present</td><td>HFrEF, angina, AF, post-MI, pregnancy (labetalol)</td></tr>
</tbody></table>
<div class="two-col">
<div>
<div class="section-title purple">SPECIAL CLINICAL SITUATIONS</div>
<table id="sp"><thead><tr><th style="text-align:left">Situation</th><th style="text-align:left">Preferred Drug(s)</th></tr></thead><tbody>
<tr><td class="td-label">Pregnancy</td><td>Methyldopa | Labetalol | Nifedipine SR</td></tr>
<tr><td class="td-label">Elderly / Isolated systolic HTN</td><td>Amlodipine | Chlorthalidone</td></tr>
<tr><td class="td-label">Black / African-descent patients</td><td>CCB or Thiazide (RAS blockers less effective as monotherapy)</td></tr>
<tr><td class="td-label">CKD + Proteinuria</td><td>ACEi or ARB (renoprotective)</td></tr>
<tr><td class="td-label">Metabolic syndrome / Pre-diabetes</td><td>ACEi or ARB or CCB (avoid thiazide+BB combo)</td></tr>
<tr><td class="td-label">Post-renal transplant</td><td>CCB (amlodipine) — first-line</td></tr>
<tr><td class="td-label">Bilateral renal artery stenosis</td><td>CCB or diuretic (AVOID ACEi / ARBs)</td></tr>
<tr><td class="td-label">Aortic aneurysm / Marfan</td><td>Beta-blocker (atenolol) or ARB (losartan)</td></tr>
<tr><td class="td-label">Migraines</td><td>Beta-blocker (propranolol, metoprolol) or verapamil</td></tr>
<tr><td class="td-label">Raynaud's phenomenon</td><td>Amlodipine. AVOID non-selective beta-blockers.</td></tr>
<tr><td class="td-label">Hyperthyroidism / Thyroid storm</td><td>Beta-blocker (propranolol)</td></tr>
</tbody></table>
</div>
<div>
<div class="section-title red">HYPERTENSIVE EMERGENCY — IV Agents</div>
<table id="em"><thead><tr><th style="text-align:left">Emergency Type</th><th>Preferred Agents</th><th>Avoid</th></tr></thead><tbody>
<tr><td class="td-label">HTN Encephalopathy</td><td>Nicardipine, Labetalol, Clevidipine</td><td>Nitroprusside</td></tr>
<tr><td class="td-label">Acute Ischaemic Stroke</td><td>Nicardipine, Labetalol, Clevidipine</td><td>Nitroprusside, Nimodipine</td></tr>
<tr><td class="td-label">Haemorrhagic Stroke</td><td>Nicardipine, Labetalol</td><td>Nitroprusside</td></tr>
<tr><td class="td-label">Aortic Dissection</td><td>Esmolol IV + Nitroprusside or Labetalol</td><td>Hydralazine</td></tr>
<tr><td class="td-label">Acute Pulmonary Oedema</td><td>IV Nitroglycerine + Furosemide + Nicardipine</td><td>Beta-blockers</td></tr>
<tr><td class="td-label">Acute MI + HTN</td><td>Beta-blocker + Nitroglycerine + ACEi</td><td>Hydralazine</td></tr>
<tr><td class="td-label">Eclampsia / Pre-eclampsia</td><td>IV Hydralazine, IV Labetalol, IV MgSO4</td><td>ACEi, ARBs</td></tr>
<tr><td class="td-label">Phaeochromocytoma Crisis</td><td>Phentolamine THEN beta-blocker</td><td>Beta-blocker FIRST!</td></tr>
<tr><td class="td-label">Scleroderma Renal Crisis</td><td>ACE Inhibitor (captopril)</td><td>ARB (less evidence)</td></tr>
</tbody></table>
<p style="font-size:10.5px;color:#c0392b;font-weight:bold;margin-top:4px;">⚠ Reduce BP max 25% in first hour. Avoid rapid drops — risk of ischaemia.</p>
</div></div>
<div class="section-title red">DRUGS TO AVOID IN SPECIFIC CONDITIONS</div>
<table id="av"><thead><tr><th style="text-align:left">Condition</th><th style="text-align:left">Drug(s) to Avoid &amp; Reason</th></tr></thead><tbody>
<tr><td class="td-label">Pregnancy</td><td>ACEi, ARBs, Direct Renin Inhibitors — all TERATOGENIC</td></tr>
<tr><td class="td-label">Bilateral renal artery stenosis</td><td>ACEi / ARBs — can precipitate acute renal failure</td></tr>
<tr><td class="td-label">Hyperkalaemia</td><td>ACEi, ARBs, MRA (spironolactone), K-sparing diuretics</td></tr>
<tr><td class="td-label">Asthma / COPD</td><td>Non-selective beta-blockers (propranolol) — bronchospasm</td></tr>
<tr><td class="td-label">AV block (2nd / 3rd degree)</td><td>Verapamil, Diltiazem, Beta-blockers — risk of asystole</td></tr>
<tr><td class="td-label">Gout</td><td>Thiazide diuretics — raise serum uric acid</td></tr>
<tr><td class="td-label">Decompensated / acute HF</td><td>Verapamil, Non-DHP CCBs — negative inotropy worsens acute failure</td></tr>
<tr><td class="td-label">Phaeochromocytoma</td><td>Beta-blockers FIRST (without alpha-blockade) — paradoxical severe HTN</td></tr>
<tr><td class="td-label">Metabolic syndrome / Diabetes risk</td><td>Thiazide + Beta-blocker combination — worsen insulin resistance</td></tr>
</tbody></table>
<div class="footer">Sources: JNC 7 · ACC/AHA 2018 · Comprehensive Clinical Nephrology 7e · NKF Primer 8e · Textbook of Family Medicine 9e · Goldman-Cecil Medicine · Lippincott Pharmacology<br>For clinical decisions, always verify against current local guidelines.</div>
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