26. Rational drug prescribing in patients with essential hypertension · Clinical Pharmacology · MU Sofia

26. Rational drug prescribing in patients with essential hypertension.

Covers rational drug choice for essential hypertension, starting with diagnostic thresholds and blood pressure targets, then lifestyle measures. It goes on to the five first-line drug classes, shown in a table of examples and key cautions, and a stepwise strategy favouring single-pill combinations and handling of resistant hypertension. A second table sets preferred drugs for diabetes, coronary disease, the elderly, pregnancy, Black patients and gout, and the note closes with hypertensive emergency management.

Inside: 4 sections · 2 tables · 16 flashcards · 2 min

Topic 26 of 30 in the MU Sofia syllabus for Clinical Pharmacology (Medicine, Year 5). The free AceMed note covers it in 4 sections, about 210 words (2 min of reading), with 16 flashcards.

Introduction

Hypertension is defined as office BP ≥ 140/90 mmHg (home ≥ 135/85, 24-h ambulatory ≥ 130/80). Treatment aims to prevent stroke, myocardial infarction, heart failure and kidney disease; each 10 mmHg fall in systolic BP cuts major cardiovascular events by about 20%.

Targets (ESC/ESH)

Most adults: < 140/90, and if tolerated systolic 120–130 mmHg (ESC 2024 suggests 120–129 for most).
Elderly and frail: individualise; avoid orthostatic hypotension.

Lifestyle (for everyone)

Salt < 5 g/day, weight loss, regular exercise, alcohol limits, stop smoking, diet rich in fruit and vegetables (DASH).

Drug treatment

Five main classes reduce cardiovascular events and are first line:

Strategy

Start most patients on a two-drug combination in a single pill: ACE inhibitor or ARB + CCB or diuretic (low-dose monotherapy only for grade 1 low-risk, very old or frail patients).
If not controlled: triple combination A + C + D in one pill.
Resistant hypertension (uncontrolled on 3 drugs including a diuretic): add spironolactone (or β-blocker, α-blocker); check adherence and secondary causes.

Choice in special situations

Hypertensive emergency (BP very high with acute organ damage): IV labetalol, nicardipine, nitroglycerin or urapidil; lower by no more than 25% in the first hour.

Start with a single-pill combination of an ACE inhibitor or ARB with a calcium channel blocker or thiazide; add the third, then spironolactone.