This document provides guidelines for drug prescription in the treatment of hypertension (HTN). It recommends the following: - First-line drugs for HTN include thiazide diuretics, calcium channel blockers (CCBs), and ACE inhibitors/ARBs. Patients under 55 should generally receive ACE inhibitors/ARBs, while those over 55 or black patients receive CCBs. - Treatment goals for blood pressure are tailored based on a patient's estimated 10-year risk of atherosclerotic cardiovascular disease. Generally, those at lower risk aim for 140/90 mmHg while higher risk patients including those with diabetes or kidney disease aim for 130/80 mmHg. - Non-pharmac

1. Drug prescription in HTN
Nehal M. Ramadan

2. • Individuals with
SBP and DBP in 2
categories should
be designated to
the higher BP
category.
• BP indicates blood
pressure (based on
an average of ≥2
careful readings
obtained on ≥2
occasions
• HPBM
• APBM
2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults
DOI: 10.1016/j.jacc.2017.11.006

3. • ASCVD (Atherosclerotic CardioVascular Disease)
1. Coronary Heart Disease (CHD),  angina & MI
2. Cerebrovascular disease,  TIAs, ischemic stroke & carotid
artery stenosis.
3. Peripheral artery disease,  claudication.
4. Aortic atherosclerotic disease,  aortic aneurysm.
• A 10-year ASCVD risk should be calculated for each
patient with HTN
• Online 10-year ASCVD risk estimators/mobile apps are
now readily accessible
Information including patient (age, sex & race); SBP & DBP;
Total cholesterol & HDL-C; DM & smoking status;
medications for HTN, are used to calculate risk.
https://tools.acc.org/ascvd-risk-estimator-
plus/#!/calculate/estimate/
• Patients with DM or CKD are automatically placed in the
high-risk category.
2 drugs (fixed dose
combinations)
1 drug
2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults
DOI: 10.1016/j.jacc.2017.11.006

4. BP targets for adults with
HTN
 BP target for adults with 10-year ASCVD risk <10% 
140/90 mm Hg
 BP target for adults with 10-year ASCVD risk ≥10% 
130/80 mm Hg
 BP target for adults with DM  130/80 mm Hg
 BP target for adults with CKD  130/80 mm Hg
 BP target for adults with HF  130/80 mm Hg
 BP target for adults with clinical ASCVD  130/80
mm Hg

5. 1. Weight loss (1 mmHg ↓ per each 1 kg loss)
2. Dietary Approaches to Stop Hypertension
(DASH): Diet rich in fruits, vegetables, whole
grains, and low-fat dairy products with reduced
content of saturated and total fat
3. Reduce Na intake to no more than 1.5 g/day
4. Maintain adequate intake of dietary K.
5. Maintain adequate intake of dietary Ca and Mg.
6. Limit daily alcohol intake to no more than 2
intakes for men 1 drink for women
7. Stop smoking
8. Engage in aerobic exercise at least 30 min daily
for most days

6. 1st-line drugs 
Thiazide diuretics (D)
CCBs (C),
ACE inhibitors/ARBs (A).
* Patients < 55 y:
- White or other  ACE
inhibitors/ARBs
- Black African  CCBs
* Patients > 55 y  CCBs
(irrespective of ethnicity)
* Patients with DM  ACE
inhibitors/ARBs (irrespective of
age & ethnicity)
N.B. ARBs are preferred over
ACE inhibitors in African
patients
N.B. ACE inhibitors/ARBs  CI
in pregnancy or in women
planning pregnancy

7. Case 1
 A 59-year-old man with type 2 diabetes presents with concerns about high
blood pressure (BP). At a recent visit to his dentist he was told his BP was high.
He was reclining in the dentist’s chair when his BP was taken, but he doesn’t
remember the exact reading. He has no symptoms. He has never taken
medications for high BP. He takes metformin for type 2 diabetes.
 His BP is measured once at 146/95 mm Hg in the left arm while sitting.
Physical exam is unremarkable except for obesity. EKG is unremarkable.
 What do you think is the next step?

8. Diagnostic and treatment decisions should be based on multiple
high quality BP measurements.
 The available data are not sufficient to
classify this patient as hypertensive. The
reading taken while reclining in the
dentist’s chair was likely inaccurate. A single
reading in the medical clinic, even with
correct technique, is not adequate for
clinical decision-making because individual
BP measurements vary in unpredictable or
random ways.
 The accuracy of BP measurement is
affected by patient
 For the first encounter, BP should be
recorded in both arms. The arm with the
higher reading should be used for
subsequent measurements.
 It is recommended that one use an average
of 2 to 3 readings, separated by 1 to 2
minutes, obtained on 2 to 3 separate visits.
Some of those readings should be
performed outside of the clinical setting,
either with HPBM or 24-hour ABPM.

9. Case 2
 A 62 year old African-American woman with prediabetes
presents for her annual physical. She has no complaints. The
average of 2 BP readings in her right arm is BP 143/88. Her
physical exam is unremarkable except for obesity. She has no
history of myocardial infarction, stroke, kidney disease, or
heart failure. After the visit, she measures her BP at home and
returns 1 month later. The average BP from multiple clinic and
home readings is 138/86.
 Her total cholesterol is 260 mg/dL, HDL 42 mg/dL, and LDL
165 mg/dL. She does not smoke.
 Her estimated 10-year ASCVD risk is shown.
 What do you think is the next step?

10. Stage 1 hypertension (HTN) is now defined as 130-139/80-89. In patients with stage
1 HTN, BP-lowering meds are recommended for those with ASCVD, diabetes, chronic
kidney disease, or estimated 10-year ASCVD risk of 10% or higher.
 With input such as her age, gender, race, lipid profile, and other risk factors, her estimated 10-
year risk is 10.5%.
 With stage 1 HTN and 10-year ASCVD risk of 10% or higher, she would benefit from a single BP-
lowering medication. In African-Americans, CCBs followed by thiazide diuretics are more
effective for lowering BP and preventing cardiovascular events compared to ACE
inhibitors/ARBs.
 Nonpharmacologic strategies  dietary changes, physical activity, and weight loss.
 If clinically appropriate, she should also avoid agents which could elevate BP, such as NSAIDs,
oral steroids, stimulants, and decongestants.
 A goal BP of 130/80 is recommended.
 After starting the new BP medication, she should monitor BP at home and return to the clinic in
1 month. If the BP goal is not met at that time despite adherence to treatment, consideration
should be given to intensifying treatment by increasing the dose of the first medication
followed by adding a second agent.

11. Case 3
 A 63 year old man with type 2 diabetes has an average BP of 151/92 over the span of several
weeks of measuring at home and in the clinic. He also has albuminuria.
 Answer:
 Stage 2 Hypertension:
 The BP treatment goal patients with diabetes and HTN is less than 130/80.
 Serious consideration should be given to starting with 2 drugs of different classes
 Given the presence of T2DM & albuminuria, an ACE inhibitor/ARB would be beneficial for
slowing progression of kidney disease + a Thiazide diuretic or a CCB
 Giving both medications as a fixed-dose combination may improve adherence.
 Never combine an ACE inhibitor and ARB  ↑ cardiovascular (dangerous hyperkalemia) and
renal risk

12. Thiazide diuretics (hydrochlorothiazide)
&
Thiazide-like diuretics (indapamide,
chlorthalidone)
 Used as monotherapy, or adjunctively with other
antihypertensive agents.
 Inhibit reabsorption of Na mostly in the distal tubules  Long-
term use of these drugs may result in hyponatremia (this is
not usually problematic)
 Increase K excretion  hypokalemia
 Decrease Ca excretion
 Decrease uric acid excretion  precipitate acute attacks of
gout.
 Thiazides should be avoided in hypokalemia and
hyponatremia.
 Drug interactions:
 Effectiveness of thiazides may be reduced by NSAIDs
(low-dose aspirin is not a concern).
 Combination of thiazides with other drugs that lower the
serum K concentration (e.g. loop diuretics) is best
12.5-50 mg
25-50 mg

13. Thiazide diuretics (hydrochlorothiazide)
&
Thiazide-like diuretics (indapamide,
chlorthalidone)
 Administration:
Best to take the tablet in the morning, so that the diuretic effect is
maximal during the day & does not therefore interfere with sleep.
 Communication:
Ask whether patients if have any difficulty getting to the toilet in time
Advise them to seek advice if they develop an acute illness that
increase risk of dehydration.
Advise that (NSAIDs) may reduce the effectiveness of diuretics.
At review, ask men directly about the possible side effect of
impotence
 Monitoring and stopping
Measure of efficacy  BP control.
Measure serum electrolyte concentrations before starting the drug, at
2–4 weeks after initiation, and after any change in therapy that might
alter electrolyte balance.
 N.B. The main SE of thiazides is hypokalemia, while one of the
main SE of ACE inhibitors/ARBs is hyperkaliemia + both drug
classes have a synergistic BP-lowering effect  the
combination of a thiazide and an ACE inhibitor/ARB is very
12.5-50 mg
25-50 mg

14. Angiotensin converting enzyme
inhibitors (ACEIs)
 The treatment of choice in patients with hypertension,
CKD and proteinuria  reduce morbidity and mortality in
patients with proteinuric renal disease (including DM)
 Should be used in patients with heart failure, angina,
recent MI  provide morbidity and mortality benefit
 ACEIs prevent the conversion of angiotensin I to
angiotensin II and block the major pathway of bradykinin
degradation by inhibiting ACE  Accumulation of bradykinin
has been proposed as a mechanism for the side effects of
cough and angioedema.
 Common side effects
 First dose hypotension
 Hyperkalaemia
 Decreased eGFR  monitor renal function regularly 
reversible on stopping the drug if detected early.
 Dry cough  switch to ARBs
 Rare but important: angioedema and other anaphylactoid
reactions  discontinue
Once or twice
Once or twice
Once

15. ACEIs and proteineuric kidney disease
 ACEIs can be used and have shown
benefit in every stage of CKD,
especially if associated with
albuminuria
 Decreased eGFR with ACEIs is inherently
linked to improved proteinuria, so 
 Check electrolytes and renal function
before starting treatment, 1–2 weeks
after initiating treatment and after
increasing the dose.
 Again, ACEIs have show benefit in
every stage of CKD
 ACEI should generally be stopped only
if serum creatinine rises more than 30%
or the estimated glomerular filtration
rate (eGFR) falls more than 25% or
serum K rises above 6 mmol/L

16. Angiotensin converting enzyme
inhibitors (ACE inhibitors)
 ACEIs are CI in
 Pregnancy and breastfeeding.
 Renal artery stenosis and acute kidney injury
 Drug interactions
 There is a potential for dangerous hyperkalemia when ACEIs are
coadministered with ARBs, K supplements or K-sparing diuretics.
 NSAID and ACEIs coadministration  increases the risk of
nephrotoxicity.
 Communication
 Advise about common side effects and possibility of severe
allergic reactions; stop taking ACEI and seek urgent medical
advice if they develop facial swelling or stomach pains.
 Emphasize the need for blood test monitoring
 Advise to avoid taking over-the-counter ‘antiinflammatories’
(NSAIDs)
 Advise to maintain their fluid intake, and stop the ACE inhibitor if
they develop diarrhea or vomiting, until their symptoms resolve 
reduce the risk of dehydration, low BP, and kidney damage.
Once or twice
Once or twice
Once

17. Angiotensin converting enzyme
inhibitors (ACE inhibitors)
 Monitoring and stopping
 Monitor efficacy on BP control
 Check electrolytes and renal function before starting
treatment, 1–2 weeks after initiating treatment and after
increasing the dose.
 ACEI should generally be stopped if serum creatinine rises
more than 30% or the estimated glomerular filtration rate
(eGFR) falls more than 25% or serum K rises above 6
mmol/L
 If serum K rises above 5 mmol/L  stop other potassium-
elevating and nephrotoxic drugs  If, despite this, it remains
above 5.0 mmol/L, reduce the ACE inhibitor dose.
Once or twice
Once
Once

18. Angiotensin receptor blockers (ARBs)
 Have similar effects to ACEIs, but
 ARBs block the action of angiotensin II on the angiotensin
type 1 (AT1) receptor
 ARBs are less likely than ACE inhibitors to cause
cough and angioedema  as they do not inhibit ACE,
so do not affect bradykinin metabolism.
 Generally, ACEIs should remain the initial treatment of
choice. ARBs are used for patients who are unable to
tolerate ACE inhibitors. Except for:
 in Black people of African or Caribbean origin who are
at higher risk of angioedema  ARBs are preferred
over ACEIs
Once
Once

19. Calcium channel blockers (CCBs)
 Calcium channel blockers (CCBs) can be divided into
dihydropyridines (DHP) and non-dihydropyridines.
 DHPs decrease Ca2+ entry into vascular smooth muscle,
which results in vasodilatation and a decrease in BP.
 They are effective as monotherapy in black patients and
elderly patients.
 Most commonly used for HTN; amlodipine 5–10 mg
orally once daily
 Adverse effects of DHPs
 Ankle swelling, flushing, headache, and palpitations,
which are caused by vasodilation and compensatory
tachycardia.
(DHP)

20. There is inadequate evidence to support beta blockers as
initial treatment unless the patient has specific
cardiovascular comorbidities (compelling indications),
e.g., heart failure, ischemic heart disease.
GDMT (guideline-directed management and therapy) beta blockers for
BP control or relief of angina include carvedilol, metoprolol, nadolol,
bisoprolol, propranolol, and timolol.
• In the treatment of hypertension in adults with
symptomatic HF  GDMT Beta-blocker + ACEI/ARB
+ diuretic + spironolactone (Mineralocorticoid
receptor antagonist; MRA) regardless of BP
• Nondihydropyridine CCBs are not recommended in
the treatment of hypertension in adults with HFrEF
• In the treatment of hypertension in adults with
angina  GDMT Beta-blocker + ACEI/ARB  initial
therapy
• If BP is not controlled  add CCBs or thiazide
diuretics
 ACEIs/ARBs can be used and have
shown benefit in every stage of
CKD, especially if associated
with albuminuria

21. As
a
nice
reference
Remember
• Chlorthalidone is the preferred thiazide based on
its long half-life and proven reduction in ASCVD
• If your patient develops angioedema due to
ACEIs  stop ACEIs  wait for 6 w  try ARBs
• Loop diuretics are preferred over thiazides ONLY
when eGFR < 30 mL/min

23.  All patients with clinical
ASCVD  Moderate/high-
intensity statin therapy
 All patients with severe
hypercholesterolemia (LDL-C
level ≥190 mg/dL)  high-
intensity statin therapy,
irrespective of age
 All patients 40-75 y of age with
DM  Moderate-intensity
statin therapy
 All patients 40-75 y of age +
an LDL-C level of 70-189
mg/dL + 10-year ASCVD ≥ 7.5%
 Moderate/high-intensity
statin therapy
 Patients 20-39 y of age 
consider statin only if LDL-C
level is ≥160 mg/dL or (family
Hx of premature ASCVD + an
LDL-C level of ≥70 mg/dL)
Adult HTN patient should be considered for statin therapy to achieve an LDL-C
target < 70 mg/dL

24. Statins
 Statins slow the atherosclerotic process and may even reverse it. They
act by competitive inhibition of 3-hydroxy-3-methyl-glutaryl coenzyme
A (HMG CoA) reductase, the enzyme that catalyzes the rate-limiting
step in cholesterol synthesis.
 Side effects:
 Statins are generally safe and well tolerated.
 The most common adverse effects are headache, GI upset, and muscle
aches.
 Rise in liver enzymes  minor biochemical changes are clinically
unimportant
 Rare but more serious  myopathy and rhabdomyolysis.
 Rare but more serious  drug-induced hepatitis
 Warnings
 Statins should be used with caution in hepatic impairment.
 Dose should be reduced in renal impairment  statins are dependent on
the kidneys for elimination of their metabolites
 Statins are CI for women who are pregnant & should be avoided in
breastfeeding.

25. Statins
 Drug interactions
 Except rosuvastatin, the metabolism of statins is impaired by cytochrome P450 (CYP) inhibitors, such as amiodarone, diltiazem,
itraconazole, macrolides, protease inhibitors, and grapefruit juice  increase the risk of myopathy.
 Amlodipine has a similar interaction  statin dosage reduction may be necessary.
 If the CYP inhibitor is being used for a short period only (e.g. clarithromycin for an acute infection)  temporarily withhold the statin.
 Only true for simvastatin, which has a short half-life, it is best taken in the evening, because cholesterol synthesis is
greatest in the early-morning hours.
 Communication
 Explain that, rarely, statins can cause muscle inflammation and damage. Therefore, they should seek medical advice if they experience
unexplained muscle pain or weakness.
 Advise them to minimize alcohol consumption.
 Those taking simvastatin or atorvastatin should avoid grapefruit juice.
 Monitoring and stopping
 Check lipid profile before starting treatment and at 3 months to evaluate LDL-C reductions
 For safety, check liver enzymes (e.g. alanine transaminase (ALT)) at baseline and again at 3 and 12 months. A rise in ALT up to three times
the upper limit of normal may be acceptable  stop if this is exceeded  can be restarted at a lower dose when liver enzymes have
returned to normal.
 Routine monitoring of creatine kinase (CK) is not required, but it should be checked during therapy if statin-induced myopathy is
suspected.

26. Thank you