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VOLUME 11 NUMBER 4 • NOVEMBER 2014
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Fixed-drug combinations are preferred because of better patient
adherence and control of BP.
22
A treatment algorithm is outlined in
Fig. 1 if the goal is not reached after initial treatment.
In black hypertensive patients a diuretic and/or a CCB is
recommended.
23
Beta-blockers should generally be avoided
in combination with diuretics as first-line therapy because of
predisposition to diabetes,
9
but this may not apply to highly selective
beta-blockers. Beta-blockers may also be considered if there is
intolerance to one of the first-line drugs. Loop diuretics such as
furosemide should not be used because of their short duration of
hypotensive activity of about six hours, unless there is evidence of
chronic kidney disease (CKD) with estimated glomerular filtration
rate (GFR) < 45 ml/min.
Management of severe hypertension
Patients with severe HTN (grade 3; BP ≥ 180/110 mmHg) may
fall into one of three categories, which determine the urgency of
their treatment. Patients should be managed or referred to the
appropriate level of care and caregiver in accordance with local
resources. Sustained, severe HTN requires immediate drug therapy
and lifestyle modification, and close follow up.
Asymptomatic severe hypertension
These patients are asymptomatic but have severe HTN without
evidence of progressive TOD or complications. The patient must
be kept in the care setting and BP measurement repeated after
resting for one hour. If still elevated at the same level, commence
oral therapy using two first-line drugs. Follow up within a week
or earlier, with escalation of treatment as needed. Early referral is
advised if BP is not controlled within two to four weeks.
Hypertensive urgencies and emergencies
24
While not common, hypertensive emergencies and urgencies
are likely to be encountered by all clinicians because of the high
prevalence of chronic HTN. It is essential that all professionals are
familiar with treatment. There is a paucity of information from well-
conducted studies on the outcomes of various antihypertensive
drugs and BP-lowering strategies.
• Hypertensive urgency
25
This level of HTN is symptomatic, usually with severe headache,
shortness of breath and oedema. There are no immediate life-
threatening neurological, renal, eye or cardiac complications, such
Table 7.
Indications and contra-indications for the major classes of antihypertensive drugs. Adapted from the ESC/ESH guidelines
9
Class
Conditions favouring the use
Contra-indications
Compelling
Possible
Diuretics
(thiazide;
thiazide-like)
• Heart failure (HF)
• Elderly hypertensives
• Isolated systolic HTN (ISH)
• Hypertensives of African origin
• Gout
• Pregnancy
•
b
-blockers (especially atenolol)
Diuretics
(loop)
• Renal insufficiency
• HF
• Pregnancy
Diuretics
(anti-aldosterone)
• HF
• Post-myocardial infarction
• Resistant hypertension
• Renal failure
• Hyperkalaemia
CCB
(dihydropyridine)
• Elderly patients
• ISH
• Angina pectoris
• Peripheral vascular disease
• Carotid atherosclerosis
• Pregnancy
• Tachyarrhythmias
• HF especially with reduced ejection
fraction
CCB non-dihydropyridine
(verapamil, diltiazem)
• Angina pectoris
• Carotid atherosclerosis
• Supraventricular tachycardia
• AV block (grade 2 or 3)
• HF
• Constipation (verapamil)
ACEI
• HF
• LV dysfunction
• Post-myocardial infarction
• Non-diabetic nephropathy
• Type 1 diabetic nephropathy
• Prevention of diabetic microalbuminuria
• Proteinuria
• Pregnancy
• Hyperkalaemia
• Bilateral renal artery stenosis
• Angioneurotic oedema (more
common in blacks than in
Caucasians)
ARB
• Type 2 diabetic nephropathy
• Type 2 diabetic microalbuminuria
• Proteinuria
• LVH
• ACEI cough or intolerance
• Pregnancy
• Hyperkalaemia
• Bilateral renal artery stenosis
b
-blockers
• Angina pectoris
• Post-myocardial infarction
• HF (carvedilol, metoprololol, bisoprolol,
nebivolol only)
• Tachyarrhythmias
• Asthma
• Chronic obstructive pulmonary
disease
• AV block (grade 2 or 3)
• Pregnancy (atenolol)
• Peripheral vascular disease
• Bradycardia
• Glucose intolerance
• Metabolic syndrome
• Athletes and physically active patients
• Non dihydropyridine CCBs (verapamil,
diltiazem)