Thiazide diuretics have been accepted as the primary foundation of antihypertensive therapy. The basis of this choice is that, apart from their primary hypotensive effect, they enhance the efficacy of other hypotensive drugs. It has been observed that most of the hypertensive patients would require 2 or more drugs for optimal control. Usually another drug from a different class can be added when BP is more than 20/10 above the goal. The drugs can be administered either separately or as fixed dose combinations. The presence of comorbid conditions should determine the choice of specific classes of hypotensive drugs.
a) Ischemic Heart Disease
In patients with hypertension and stable angina the drug of choice is usually a beta-blocker, with or without a long acting calcium channel blocker. In unstable angina, a beta-blocker, diltiazem and ACE inhibitors or an ARB are the preferred ones. In post infarction states beta-blockers and ACEI/ARB are the choices.
b) Heart Failure
With the current interest in diastolic heart failure there is a greater interest in the management of diastolic dysfunction usually detected on echocardiography. Beta-blockers and ACEI/ARB are the choices. Diuretics are not recommended since they decrease the LV filling pressure. In early systolic dysfunction, ACE/ARB are given. In florid heart failure it has to be diuretics, aldosterone antagonists, ARB/ACEI are recommended.
c) Diabetic with Hypertension
ACEI and ARBs are first choice since they have been found to retard the progression of diabetic nephropathy and may reduce albuminuria. Other drugs can be added to obtain the target BP of 130/80.