Individualised Selection of Antihypertensive Therapy

Theoretically, it should be possible to match the requirements of individual patients with the pharmacological and clinical properties of the large number of antihypertensive drugs now available. The concept of automatic sequential stepped-care therapy is now largely outdated, but therapy of clinically important hypertension must be initiated with one agent. Diuretics remain a first-line option in the elderly and in Black patients, as do calcium antagonists. Outcome trials are available only for the elderly, and in these the benefits of initial diuretic therapy are well documented. Nonetheless, diuretics may often need to be co-prescribed with a beta-blocker or an adrenergic modifier such as methyldopa. beta-Blockers are preferred in patients with ischaemic heart disease or enhanced adrenergic drive, while alpha-blockers are preferred in patients with blood lipid abnormalities or prostatic problems. Calcium antagonists or angiotensin converting enzyme (ACE) inhibitors are being increasingly used as initial therapy when quality of life is important and metabolic neutrality is required. Calcium antagonists are more likely to be effective first-line therapy than ACE inhibitors in patients with a high salt intake, in patients with Raynaud's disease, when angina pectoris is present, and in Black patients. ACE inhibitors are preferred for combination with diuretic agents, and in the presence of congestive heart failure or low salt intake. Experimentally, both calcium antagonists and ACE inhibitors can prevent ischaemic ventricular fibrillation and atheroma. Combination therapy between these 2 drug classes is gaining increasing acceptance because of these theoretical advantages.(ABSTRACT TRUNCATED AT 250 WORDS)