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High Blood Pressure. The Facts About HBP. Understanding Blood Pressure Readings. Why HBP is a "Silent Killer". Health Threats from HBP. Changes You Can Make to Manage High Blood Pressure. Baja Tu Presión.

Find HBP Tools and Resources. Blood Pressure Toolkit. Home Health Topics High Blood Pressure Changes You Can Make to Manage High Blood Pressure Managing Medications. When your health care professional prescribes blood pressure medication As part of a solution designed to fit your needs, your health care professional may determine that you need prescription medication in addition to lifestyle changes to control your high blood pressure , also known as hypertension.

Talk to your doctor and pharmacist if you have concerns. Blood pressure medicines can work several different ways. Blood pressure medicines can keep blood pressure at a healthy level by 1 :.

Talk with your health care team about the best type of treatment for you. You may need to take more than one type of medicine to control your blood pressure.

You can also talk to your health care team about how long it should take your blood pressure medicine to work. It is important to take your blood pressure medicine exactly as your doctor tells you to. Do not stop taking your current medicine without talking to your doctor or pharmacist first.

Stopping your blood pressure medicine without first talking to your health care team could lead to serious health consequences. The benefits of blood pressure medicines are clear: Blood pressure medicines can help you keep your blood pressure at healthy levels and therefore greatly reduce your risk of heart disease , heart attack , and stroke.

In general, the risks of taking blood pressure medicines are low. However, all medicines have risks. Talk with your doctor or health care professional about the risks of high blood pressure medicines.

Do not stop taking your current medicine without talking to your doctor or health care professional first. Wires connect the sensors to a machine, which prints or displays results.

This noninvasive exam uses sound waves to create detailed images of the beating heart. It shows how blood moves through the heart and heart valves.

Taking your blood pressure at home Your health care provider may ask you to regularly check your blood pressure at home. Home blood pressure monitors are available at local stores and pharmacies. More Information.

Blood pressure chart. Blood pressure test. Your health care provider may recommend that you make lifestyle changes including: Eating a heart-healthy diet with less salt Getting regular physical activity Maintaining a healthy weight or losing weight Limiting alcohol Not smoking Getting 7 to 9 hours of sleep daily Sometimes lifestyle changes aren't enough to treat high blood pressure.

Medications The type of medicine used to treat hypertension depends on your overall health and how high your blood pressure is. Medicines used to treat high blood pressure include: Water pills diuretics.

Angiotensin-converting enzyme ACE inhibitors. These drugs help relax blood vessels. They block the formation of a natural chemical that narrows blood vessels.

Examples include lisinopril Prinivil, Zestril , benazepril Lotensin , captopril and others. Angiotensin II receptor blockers ARBs. These drugs also relax blood vessels. They block the action, not the formation, of a natural chemical that narrows blood vessels.

angiotensin II receptor blockers ARBs include candesartan Atacand , losartan Cozaar and others. Other medicines sometimes used to treat high blood pressure If you're having trouble reaching your blood pressure goal with combinations of the above medicines, your provider may prescribe: Alpha blockers.

These medicines reduce nerve signals to blood vessels. They help lower the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin Cardura , prazosin Minipress and others. Alpha-beta blockers. Alpha-beta blockers block nerve signals to blood vessels and slow the heartbeat.

They reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol Coreg and labetalol Trandate. Aldosterone antagonists. These drugs may be used to treat resistant hypertension.

They block the effect of a natural chemical that can lead to salt and fluid buildup in the body. Examples are spironolactone Aldactone and eplerenone Inspra. These medicines stop the muscles in the artery walls from tightening. This prevents the arteries from narrowing. Examples include hydralazine and minoxidil.

Central-acting agents. These medicines prevent the brain from telling the nervous system to increase the heart rate and narrow the blood vessels. Examples include clonidine Catapres, Kapvay , guanfacine Intuniv and methyldopa. Treating resistant hypertension You may have resistant hypertension if: You take at least three different blood pressure drugs, including a diuretic.

But your blood pressure remains stubbornly high. You're taking four different medicines to control high blood pressure.

Your care provider should check for a possible second cause of the high blood pressure. Treating resistant hypertension may involve many steps, including: Changing blood pressure medicines to find the best combination and dosage.

Reviewing all your medicines, including those bought without a prescription. Checking blood pressure at home to see if medical appointments cause high blood pressure.

This is called white coat hypertension. Eating healthy, managing weight and making other recommended lifestyle changes. High blood pressure during pregnancy If you have high blood pressure and are pregnant, discuss with your care providers how to control blood pressure during your pregnancy.

Potential future treatments Researchers have been studying the use of heat to destroy specific nerves in the kidney that may play a role in resistant hypertension. Request an appointment. Alpha blockers.

Angiotensin II receptor blockers. Show more related information. Choosing blood pressure medicines. Beta blockers: Do they cause weight gain? Beta blockers: How do they affect exercise? Blood pressure medications: Can they raise my triglycerides?

Calcium supplements: Do they interfere with blood pressure drugs? Diuretics: A cause of low potassium? From Mayo Clinic to your inbox. Sign up for free and stay up to date on research advancements, health tips, current health topics, and expertise on managing health.

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You may opt-out of email communications at any time by clicking on the unsubscribe link in the e-mail. Clinical trials. Try these heart-healthy strategies: Eat healthy foods.

Eat a healthy diet. Try the Dietary Approaches to Stop Hypertension DASH diet. Choose fruits, vegetables, whole grains, poultry, fish and low-fat dairy foods. Get plenty of potassium from natural sources, which can help lower blood pressure.

Eat less saturated fat and trans fat. Use less salt. Processed meats, canned foods, commercial soups, frozen dinners and certain breads can be hidden sources of salt.

Check food labels for the sodium content. Limit foods and beverages that are high in sodium. A sodium intake of 1, mg a day or less is considered ideal for most adults.

But ask your provider what's best for you. Limit alcohol. Even if you're healthy, alcohol can raise your blood pressure. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women, and up to two drinks a day for men.

One drink equals 12 ounces of beer, 5 ounces of wine or 1. Don't smoke. Tobacco injures blood vessel walls and speeds up the process of hardening of the arteries.

If you smoke, ask your care provider for strategies to help you quit. Maintain a healthy weight. If you're overweight or have obesity, losing weight can help control blood pressure and lower the risk of complications. Ask your health care provider what weight is best for you. In general, blood pressure drops by about 1 mm Hg with every 2.

In people with high blood pressure, the drop in blood pressure may be even more significant per kilogram of weight lost. Practice good sleep habits. Poor sleep may increase the risk of heart disease and other chronic conditions. Adults should aim to get 7 to 9 hours of sleep daily.

Kids often need more. Go to bed and wake at the same time every day, including on weekends. If you have trouble sleeping, talk to your provider about strategies that might help.

Manage stress. Find ways to help reduce emotional stress. Getting more exercise, practicing mindfulness and connecting with others in support groups are some ways to reduce stress. Try slow, deep breathing. Practice taking deep, slow breaths to help relax.

Some research shows that slow, paced breathing 5 to 7 deep breaths per minute combined with mindfulness techniques can reduce blood pressure. There are devices available to promote slow, deep breathing. According to the American Heart Association, device-guided breathing may be a reasonable nondrug option for lowering blood pressure.

It may be an good option if you have anxiety with high blood pressure or can't tolerate standard treatments. High blood pressure and exercise. Medication-free hypertension control. Stress and high blood pressure. Blood pressure medication: Still necessary if I lose weight?

Can whole-grain foods lower blood pressure? High blood pressure and cold remedies: Which are safe? Resperate: Can it help reduce blood pressure? How to measure blood pressure using a manual monitor. How to measure blood pressure using an automatic monitor. What is blood pressure? These supplements include: Fiber, such as blond psyllium and wheat bran Minerals, such as magnesium, calcium and potassium Folic acid Supplements or products that increase nitric oxide or widen blood vessels — called vasodilators — such as cocoa, coenzyme Q10, L-arginine and garlic Omega-3 fatty acids, found in fatty fish, high-dose fish oil supplements and flaxseed Researchers are also studying whether vitamin D can reduce blood pressure, but evidence is conflicting.

L-arginine: Does it lower blood pressure? Some things you can do to help manage the condition are: Take medicines as directed. If side effects or costs pose problems, ask your provider about other options.

Don't stop taking your medicines without first talking to a care provider. Schedule regular health checkups. It takes a team effort to treat high blood pressure successfully. Work with your provider to bring your blood pressure to a safe level and keep it there.

Know your goal blood pressure level. Choose healthy habits. Eat healthy foods, lose excess weight and get regular physical activity. If you smoke, quit. Say no to extra tasks, release negative thoughts, and remain patient and optimistic. Ask for help. Sticking to lifestyle changes can be difficult, especially if you don't see or feel any symptoms of high blood pressure.

It may help to ask your friends and family to help you meet your goals. Join a support group. You may find that talking about any concerns with others in similar situations can help. What you can do Write down any symptoms that you're having. High blood pressure rarely has symptoms, but it's a risk factor for heart disease.

Let your care provider know if you have symptoms such as chest pains or shortness of breath. Doing so can help your provider decide how aggressively to treat your high blood pressure.

Write down important medical information, including a family history of high blood pressure, high cholesterol, heart disease, stroke, kidney disease or diabetes, and any major stresses or recent life changes.

Make a list of all medicines, vitamins or supplements that you're taking. Include dosages. Take a family member or friend along, if possible.

Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot. Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, be ready to talk to your care provider about any challenges you might face in getting started.

Write down questions to ask your provider. For high blood pressure, some basic questions to ask your provider include: What kinds of tests will I need? What is my blood pressure goal?

Do I need any medicines? Is there a generic alternative to the medicine you're prescribing for me? What foods should I eat or avoid?

What's an appropriate level of physical activity? How often do I need to schedule appointments to check my blood pressure? Should I monitor my blood pressure at home?

I have other health conditions. How can I best manage them together? Are there brochures or other printed material that I can have? What websites do you recommend? Don't hesitate to ask any other questions that you might have. What to expect from your doctor Your health care provider is likely to ask you questions.

Your provider may ask: Do you have a family history of high cholesterol, high blood pressure or heart disease?

What are your diet and exercise habits like? Do you drink alcohol? How many drinks do you have in a week? Do you smoke? When did you last have your blood pressure checked?

In the sequential monotherapy group, the dose of the first drug was doubled at four weeks; at eight weeks, the first drug was replaced by the other drug, and the dose of that drug was doubled at twelve weeks.

Starting at 16 weeks, combination therapy was used. Blood pressure reduction was greater with initial combination therapy than with sequential monotherapy, although the blood pressures in the two groups became similar once the sequential monotherapy group was switched to combination therapy [ 11 ].

After the sequential monotherapy group was switched to combination therapy, the control rate increased to match the initial combination therapy group. By contrast, there is interindividual heterogeneity in the blood pressure response to specific antihypertensive medications [ ], and therefore switching from one drug that has a suboptimal effect to a different drug may lead to improved control [ ].

In addition, there is one trial that reported numerically similar proportions of hypertension control comparing a stepped-care approach with sequential monotherapy [ 10 ]. However, the agents and dosing strategies that were used in this trial were different in the stepped-care and sequential monotherapy groups, limiting the interpretation of this study.

Despite recommendations to add an additional antihypertensive drug when the patient has not attained goal blood pressure, clinicians frequently fail to do this in practice therapeutic inertia. In the United States, for example, the number of antihypertensive drugs prescribed to adults with hypertension has not changed over the past decade, even though the prevalence of poor hypertension control is high and increasing [ ].

Of those individuals with uncontrolled hypertension, 40 percent are treated with only one antihypertensive medication. Adding a second drug preferred combination therapy — In most patients who require two antihypertensive agents, the drugs should generally be selected from among the three preferred classes ie, ACE inhibitors [or angiotensin receptor blockers ARBs ], dihydropyridine calcium channel blockers, and thiazide diuretics [ideally a thiazide-like rather than a thiazide-type diuretic].

Conversely, some patients may have an indication for a drug from a different class, as described previously table 2. See 'Choice of initial therapy in patients with comorbidities' above. However, among those without an indication for one of the nonpreferred agents, we suggest treating with the combination of an ACE inhibitor or ARB and a calcium channel blocker, preferably a dihydropyridine calcium blocker.

In addition, we suggest prescribing these two agents as a single-pill combination, if feasible algorithm 1. Patients were randomly assigned to treatment with benazepril 40 mg daily plus amlodipine 5 to 10 mg daily or benazepril plus hydrochlorothiazide At three years, the composite cardiovascular endpoint ie, the combination of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, resuscitation after sudden cardiac death, or coronary revascularization occurred less frequently in the benazepril plus amlodipine group 9.

Benazepril-amlodipine therapy led to a similar reduction in the composite of cardiovascular death or nonfatal myocardial infarction or stroke 5 versus 6. All-cause mortality was slightly less common in the benazepril plus amlodipine group 4.

Although office-based systolic pressure was slightly higher in the group receiving hydrochlorothiazide by 1 mmHg [ 30 ], the hour average ambulatory systolic pressure was 1. Thus, differences in attained blood pressure likely do not account for the totality of the observed benefit from combining benazepril with amlodipine.

In addition to the cardiovascular benefits, kidney events defined as doubling of serum creatinine or end-stage kidney disease [ESKD] were less frequent in patients who were assigned to benazepril plus amlodipine 2 versus 3.

However, as noted above, thiazide-like diuretics chlorthalidone and indapamide are more potent and are therefore preferred over thiazide-type diuretics. Whether combining an ACE inhibitor or ARB with a dihydropyridine calcium channel blocker is superior to combining it with a thiazide-like diuretic is unknown.

Nevertheless, because single-pill combinations that contain a thiazide-like diuretic are few and often difficult to obtain, we favor the combination of an ACE inhibitor or ARB plus a dihydropyridine calcium channel blocker when two agents are required.

Adding a third drug if needed — As noted earlier, the three primary options for antihypertensive drug therapy in most patients include an ACE inhibitor or ARB , dihydropyridine calcium channel blocker, and thiazide diuretic preferably a thiazide-like diuretic [ 3 ].

Thus, in patients whose blood pressure is uncontrolled despite adherence to two drugs, we add a drug from the third class of agents. As an example, in a patient who has not attained goal blood pressure despite taking an ACE inhibitor and calcium channel blocker, we add a thiazide-like diuretic.

Some patients may have an indication for a drug from a different class, as described previously table 2. Apparent treatment-resistant hypertension — Patients who are prescribed three antihypertensive drugs at intermediate or high or maximally tolerated doses, inclusive of a diuretic, and who have uncontrolled blood pressure are defined as having apparent treatment-resistant hypertension; those prescribed four or more medications whether or not their blood pressure is controlled are also defined as having apparent treatment-resistant hypertension.

The word "apparent" is used because many such patients have pseudoresistant hypertension eg, due to nonadherence to prescribed therapy or white coat effect. This issue is presented in detail elsewhere. See "Definition, risk factors, and evaluation of resistant hypertension", section on 'Apparent, true, and pseudoresistant hypertension'.

Apparent resistant hypertension is relatively common. As an example, in an analysis of National Health and Nutrition Examination Survey NHANES data through , 22 percent of drug-treated individuals with hypertension were prescribed three or more antihypertensive drugs.

Given that nonadherence and white coat effect are prevalent, the proportion of patients with true resistant hypertension is likely considerably less.

See "Definition, risk factors, and evaluation of resistant hypertension", section on 'Prevalence'. Refractory hypertension is defined as having uncontrolled blood pressure despite prescription of five or more antihypertensive drugs.

In one study, approximately 6 percent of those with apparent resistant hypertension had refractory hypertension [ ]. Compared with patients who have apparent resistant hypertension, those with refractory hypertension have higher rates of kidney failure and cardiovascular disease [ ].

In addition, rates of nonadherence to therapy are higher among those with apparent refractory hypertension 60 percent in one study [ ]. See "Definition, risk factors, and evaluation of resistant hypertension", section on 'Refractory hypertension'.

The evaluation and treatment of patients with resistant and refractory hypertension is presented separately algorithm 3 and figure 2. See "Definition, risk factors, and evaluation of resistant hypertension" and "Treatment of resistant hypertension".

Waiting four weeks to reevaluate after starting or intensifying therapy is typically appropriate to permit long-acting antihypertensive drugs enough time to manifest their full blood pressure-lowering effect. Reevaluating at two weeks or even sooner is appropriate for patients with severely elevated blood pressure.

If blood pressure is uncontrolled, we typically escalate doses of individual antihypertensive drugs to at least half the maximum recommended dose ie, to a moderate or high dose before adding additional therapy.

After goal blood pressure is attained, we usually follow patients every three to six months either in person or by telehealth. To determine if a patient has attained goal blood pressure, it is important that blood pressure be measured appropriately.

As discussed elsewhere, there are four methods to properly measure blood pressure see "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Our approach to measuring blood pressure' :.

The technology of devices available for self-measured blood pressure has advanced considerably. Now, many home monitors contain memory that automatically stores readings, and some even have the capability of making automated readings while asleep.

If home monitoring is performed, the patient should be trained in proper self-measurement technique, and the accuracy of their device should be periodically evaluated eg, annually.

Self-measured blood pressure is discussed in detail elsewhere. See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring". We monitor electrolytes and serum creatinine one to three weeks after initiation or titration of angiotensin-converting enzyme ACE inhibitors, angiotensin receptor blockers ARBs , mineralocorticoid receptor antagonists, and diuretics table 5.

In patients on stable doses of medications, electrolytes and creatinine are typically monitored annually. OVERVIEW OF ADVERSE EFFECTS — Adverse effects of commonly used antihypertensive drugs are discussed in detail elsewhere table 5 :. BEDTIME VERSUS MORNING DOSING — The contributors to this topic take different approaches to the timing of antihypertensive therapy:.

This approach is supported by the European Society of Hypertension ESH [ ]. Patients with glaucoma, particularly open-angle glaucoma, should not be prescribed antihypertensive medicines at night [ ].

The best data come from the Treatment In the Morning or Evening TIME trial [ ]. In this study, more than 21, adults with hypertension were randomly assigned to take their antihypertensive medications in the morning or the evening. At approximately five years, rates of cardiovascular events were similar between the groups.

There were no important differences in safety or adverse events comparing morning with evening dosing. Although not specifically designed to compare morning with evening dosing, the Colchicine for Prevention of Vascular Inflammation in Noncardioembolic Stroke CONVINCE trial compared sustained release verapamil given at bedtime with an active comparator either hydrochlorothiazide or atenolol , which were dosed in the morning ; there was no difference in the rates of cardiovascular events among the groups [ ].

These data conflict with two other trials the MAPEC and Hygia studies , which concluded that evening dosing leads to fewer cardiovascular events and lower mortality compared with morning dosing [ ,, ]. However, both the MAPEC and Hygia trials were published by the same research group and both trials reported very large benefits from shifting one or more antihypertensive drugs from the morning to bedtime eg, 50 percent or greater relative reductions in stroke, myocardial infarction, and cardiovascular death.

Effects of this magnitude are rarely if ever observed in rigorous cardiovascular trials; in addition, the biologic rationale a modest reduction in nighttime blood pressure without a major difference in hour blood pressure does not support such large effects [ ].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Hypertension in adults". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.

Our approach is as follows see 'Choosing between monotherapy and combination drug therapy' above :. Combination therapy lowers blood pressure more than monotherapy and increases the likelihood that target blood pressure will be achieved in a reasonable time period.

In addition, using two drugs may lead to attainment of goal blood pressure with lower doses of each medication, and this reduces the risk of dose-related side effects. Such patients include those adhering to a very low salt intake, those who are underweight or frail, those with a known orthostatic decline in blood pressure, and those with a history of multiple drug allergies or intolerances.

However, by far the most important strategy for ultimately achieving blood pressure control is to avoid therapeutic inertia. In most patients, the drugs should be selected from among the three preferred classes ie, angiotensin-converting enzyme [ACE] inhibitors [or angiotensin receptor blockers ARBs ], calcium channel blockers, and thiazide diuretics [ideally a thiazide-like rather than a thiazide-type diuretic].

Among patients without an indication for a specific drug class, we suggest treating with the combination of an ACE inhibitor or ARB and a calcium channel blocker, preferably a dihydropyridine calcium blocker, rather than other combinations Grade 2B.

In addition, we suggest prescribing these two agents as a single-pill combination, if feasible table 1 and algorithm 1 Grade 2B. If there are no compelling reasons to select a specific drug class, we suggest treating with an ACE inhibitor or ARB or a dihydropyridine calcium channel blocker, rather than a thiazide diuretic algorithm 1 Grade 2C.

A thiazide diuretic is a reasonable alternative as monotherapy and may be preferred in patients with edema, osteoporosis, or calcium nephrolithiasis with hypercalciuria. If a thiazide diuretic is used, we suggest treating with a thiazide-like diuretic ie, chlorthalidone , indapamide rather than hydrochlorothiazide Grade 2C.

See 'Patients selected for initial monotherapy' above. Before escalating antihypertensive drug therapy, it is generally prudent to confirm that the patient is adherent and that the blood pressure is truly above goal either with out-of-office blood pressure measurements or a series of properly performed office-based measurements.

See 'Assess medication adherence' above and 'Assure proper blood pressure measurement' above. See 'Uncontrolled on monotherapy' above.

As noted above, among those without an indication for one of the nonpreferred agents, we suggest treating with the combination of an ACE inhibitor or ARB and a calcium channel blocker, preferably a dihydropyridine calcium blocker Grade 2B.

In addition, we suggest prescribing these two agents as a single-pill combination, if feasible algorithm 1 Grade 2B. Resistant hypertension is presented in detail elsewhere algorithm 3 and figure 2. See 'Dose titration and monitoring' above. We monitor electrolytes and serum creatinine one to three weeks after initiation or titration of ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and diuretics table 5.

Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you. View Topic. Font Size Small Normal Large. Choice of drug therapy in primary essential hypertension.

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Authors: Johannes FE Mann, MD John M Flack, MD, MPH, FAHA, FASH, MACP Section Editors: George L Bakris, MD William B White, MD Deputy Editors: Karen Law, MD, FACP John P Forman, MD, MSc Contributor Disclosures.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Jan 30, Choice of initial therapy in patients with comorbidities Patients with heart failure — Patients with heart failure may have reduced ejection fraction ie, HFrEF , mildly reduced ejection fraction ie, HFmrEF , or preserved ejection fraction ie, HFpEF.

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Circ Arrhythm Electrophysiol ; Feenstra RK, Allaart CP, Berkelmans GFN, et al. Additional benefits may include cost savings and better compliance. Potential disadvantages include increased cost for some combinations, increased risk of adverse events and drug-drug interactions, and patients' perception that taking more medications is equated with being sicker this may be partially addressed by the use of a fixed-dose combination pill.

Patients with comorbidities may benefit from the effects of different antihypertensive medications and warrant consideration for combination therapy. For example, a patient with hypertension and diabetes, heart failure, or renal disease may benefit from the combination of a diuretic and an angiotensin-converting enzyme ACE inhibitor.

When monotherapy fails to achieve target blood pressure, using combination therapy is an alternative to increasing the dose of a single agent 1 Table 1 1 , 10 , A number of studies evaluated the effectiveness of different antihypertensive agents in decreasing all-cause mortality and, secondarily, decreasing cardiovascular morbidity and mortality.

Although these studies often seek to establish the superiority of an agent or a combination of agents, interpretation of results is often complicated by differences in blood pressure lowering between treatment groups, 12 — 14 which alone could account for any observed benefit. The choice of antihypertensive agents is guided by clinical guidelines and patient characteristics Table 2.

A number of diuretic combinations are available Table 3 19 , Antihypertensive agents can have complementary effects and may help offset each other's adverse effects. Combination therapies demonstrating synergistic or complementary mechanisms of action include beta blocker-diuretic; 21 angiotensin receptor blocker ARB -diuretic; 22 , 23 ACE inhibitor-diuretic; 21 calcium channel blocker-ACE inhibitor; 4 , 24 , 25 calcium channel blocker-diuretic; 16 and a thiazide diuretic plus a potassium-sparing diuretic.

A randomized controlled trial of hypertensive patients with increased cardiovascular risk evaluating treatment with amlodipine Norvasc plus perindopril Aceon; a calcium channel blocker plus an ACE inhibitor, if needed or atenolol Tenormin plus bendroflumethiazide Naturetin; a beta blocker plus a diuretic, if needed , demonstrated that a calcium channel blocker-ACE inhibitor combination was superior to a beta blocker-diuretic combination in reducing cardiovascular morbidity and mortality and in preventing new-onset diabetes.

Initial data of an ongoing trial comparing a combination pill containing a calcium channel blocker and an ACE inhibitor with a combination pill containing an ACE inhibitor and a diuretic on cardiovascular morbidity and mortality in patients with hypertension has demonstrated statistically significant blood pressure reductions using initial treatment combination therapy compared with the participants' pre-study enrollment antihypertensive drug regimens.

Another randomized trial compared valsartan Diovan , an ARB-based treatment, with amlodipine, a calcium channel blocker-based treatment, in patients with hypertension who are at an increased cardiovascular risk.

Despite improved blood pressure lowering in the amlodipine group, there was no decrease in cardiovascular morbidity or mortality between the study groups except for a decreased incidence of myocardial infarction in the patients treated with amlodipine.

The following combinations demonstrate particular risks: a nondihydropyridine calcium channel blocker with a beta blocker risk of bradycardia , 1 and an ACE inhibitor or ARB with an aldosterone antagonist risk of hyperkalemia. Fixed-dose combination treatments offer several potential benefits, including simplification of the treatment regimen, convenience, and sometimes decreased cost.

Disadvantages include initial doses that are often below those that would be started with monotherapy, making it potentially more difficult to achieve the desired dose, and the risk of causing orthostatic hypotension in older patients and patients with diabetic autonomic neuropathy.

Approximately 70 percent of patients with hypertension will require two or more agents to achieve their target blood pressure. JNC-7 guidelines recommend diuretics, beta blockers, ACE inhibitors, ARBs, and aldosterone antagonists aldosterone antagonists include eplerenone [Inspra] and spironolactone [Aldactone] in the treatment of hypertensive patients with heart failure.

Aldosterone antagonists are beneficial in the treatment of moderate to severe heart failure, but may not offer the same benefit to patients with less severe heart failure or with significant renal failure. In patients with hypertension at high risk of coronary disease, JNC-7 guidelines recommend the use of diuretics, calcium channel blockers, beta blockers, and ACE inhibitors.

Patients with hypertension and diabetes have lower rates of blood pressure control 7 and often require combination therapy. The calcium channel blocker-ACE inhibitor combination has demonstrated superior blood pressure lowering compared with ACE inhibitor monotherapy in patients with hypertension and diabetes.

The U. Prospective Diabetes Study Group found that blood pressure control was more important than tight blood glucose control at preventing cardiovascular events, and that an ACE inhibitor and a beta blocker were equivalent in their benefit, although 30 percent of patients in both groups required three or more medications to control their blood pressure.

Diabetes and hypertension are the two leading causes of end-stage renal disease. Combination therapy is often needed to effectively lower blood pressure to goal levels in patients with kidney disease because monotherapy rarely attains the level of blood pressure lowering required to slow the decline in glomerular filtration rate.

JNC-7 guidelines recommend diuretics and ACE inhibitors for secondary stroke prevention. In a study evaluating an ARB versus a calcium channel blocker for secondary stroke prevention, two thirds of patients in both treatment arms required at least one additional agent to achieve adequate blood pressure lowering.

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