Hypertension Management

Alternative Antihypertensive Medications

• Thiazide diuretics, calcium channel blockers (CCBs), and beta-blockers are primary alternative antihypertensive medication classes besides ACE inhibitors and ARBs, with mineralocorticoid receptor antagonists as an additional option for resistant hypertension, according to the American Heart Association and American College of Cardiology [1]
• The American Heart Association, American College of Cardiology, and Centers for Disease Control and Prevention guidelines recommend thiazide diuretics as first-line therapy for most patients [1]
• Long-acting thiazide diuretics, such as chlorthalidone and indapamide, are preferred due to better cardiovascular outcomes [3]
• Thiazide diuretics are particularly effective in Black patients and older adults (>55 years) [1]
• Dihydropyridine CCBs, such as amlodipine and nifedipine, are preferred for hypertension [3]
• CCBs are particularly effective in Black patients and older adults (>55 years) [1]
• Non-dihydropyridine CCBs, such as diltiazem and verapamil, should be avoided in heart failure with reduced ejection fraction [4]
• Beta-blockers are recommended by the Canadian Hypertension Education Program guidelines as a first-line option [1]
• Beta-blockers are particularly beneficial in patients with coronary artery disease, post-myocardial infarction, or heart failure [4, 5]
• Beta-1 selective agents, such as metoprolol and bisoprolol, are preferred in patients with chronic obstructive pulmonary disease [2]
• Mineralocorticoid receptor antagonists are recommended for resistant hypertension (uncontrolled on 3 medications including a diuretic) [3]
• Mineralocorticoid receptor antagonists are particularly effective when added to ACE/ARB, thiazide, and CCB combination [3]
• Eplerenone showed a 15% mortality reduction in post-myocardial infarction patients with left ventricular dysfunction [5]

Combination Therapy

• Multiple-drug therapy is often required to achieve blood pressure targets [3]
• Effective two-drug combinations include CCB + thiazide diuretic, CCB + beta-blocker, and thiazide diuretic + beta-blocker [1]
• For three-drug combinations, CCB + thiazide + beta-blocker is recommended [1]

Special Considerations

• Beta-blockers are first-line therapy regardless of blood pressure levels [2]
• CCBs can be added if blood pressure control is inadequate [2]
• Thiazide diuretics are effective if estimated glomerular filtration rate (eGFR) >30 mL/min/1.73m² [2]
• Loop diuretics should be used if eGFR <30 mL/min/1.73m² [2]
• Monitor renal function and electrolytes regularly [3]
• Regular monitoring of electrolytes is essential with diuretics and mineralocorticoid receptor antagonists [3]
• Start beta-blockers with low doses and titrate gradually to avoid bradycardia and hypotension [4]
• Consider adding a mineralocorticoid receptor antagonist before trying less evidence-based alternatives for resistant hypertension [3]