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Treatment Recommendations for Specific Patients

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Updated June 06, 2007

Many patients with high blood pressure wonder if there is one particular medication option that is better than the others. Because adequate control of high blood pressure depends on a wide variety of patient specific factors, the answer is usually no. Sometimes, though, certain patients can potentially benefit from certain medications. When other medical conditions are present along with high blood pressure, there is data which shows that certain medications may be better than others.

Patients with Diabetes

Diabetes and high blood pressure are linked in many subtle and complicated ways. High blood pressure, and high blood pressure treatment, can contribute to the development or worsening of certain kinds of diabetes. In turn, diabetes can lead to high blood pressure by causing organ and blood vessel damage.

Patients with diabetes usually receive treatment for high blood pressure at lower overall blood pressures than patients without diabetes. This is because diabetes and high blood pressure can work together to cause a common set of complications, which early blood pressure control can help to prevent. First choice drugs for patients with diabetes are generally ACE inhibitors and angiotensin receptor blockers. These drugs have been shown to offer some protection for the kidneys, which can be damaged by diabetes. Often, additional drugs may be needed in order to obtain the tight blood pressure control that these patients require. In these cases, calcium channel blockers are usually preferred.

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Elderly Patients

Older patients tend to have a higher incidence of side effects from drug treatment, regardless of the disease being treated. Because older people also tend to have more health problems than younger people, it is more likely that they will already be taking some medications before starting treatment for high blood pressure, which raises the risk of complications from drug interactions.

Because of this, it is important for older patients to initially be treated with mild drugs that have a low incidence of side effects and interactions with other drugs. In most cases, that means the drug of choice is some form of diuretic. Diuretics are a well established class of medication with a mild and well studied side effect profile. Beta blockers may also be a first choice - either alone or in combination with a diuretic - if there are other factors to suggest the patient may be at risk for heart attack or stroke.


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Patients with a History of Heart Attack

Because a wide variety of risk factors and lifestyle issues can contribute to having a heart attack, it may be difficult to separate one specific thing that could be benefit from a particular drug. It is clear, though, that high blood pressure in patients who have already had a heart attack is dangerous and must be aggressively controlled. This need for aggressive control means that these patients are often treated with combinations of several drugs. In general, ACE inhibitors and beta blockers are the first choice drugs for these patients.


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Pregnant Patients

For the majority of women who develop high blood pressure during pregnancy, the risks are small and the treatment of choice is typically careful monitoring. If the high blood pressure worsens, or begins to progress to preeclampsia, then some type of treatment is usually warranted.

Unfortunately, while modern drugs are very effective in the treatment of high blood pressure, almost all of them are unsafe to use during pregnancy. ACE inhibitors and angiotensin receptor blockers, for example, are known to have harmful effects on the fetus, including kidney damage and death. Because of similar dangers, beta blockers should not be given to women during their first trimester (though their use later in the pregnancy may be considered).

The most well studied studied drug for treating high blood pressure during pregnancy is called Methyldopa. Methyldopa lowers blood pressure by relaxing blood vessels, and was once an important part of general high blood pressure treatment. With the development of newer drugs the use of methyldopa as a general high blood pressure treatment has greatly diminished. Because of its generally a safe drug, though, it remains an important option in treating high blood pressure during pregnancy.


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Individual Treatment Decisions

Remember that no single blood pressure medicine is the right choice in all circumstances. Even if you have diabetes, or have had a heart attack, your doctor may choose to treat you with drugs other than those listed here. This is because other circumstances may modify these general recommendations. If you're confused about why you're taking one drug instead of another, be sure to ask your doctor.


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Sources:

  1. Chobanian, AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003; 289:2560.
  2. Davis, BR, et al. Role of Diuretics in the Prevention of Heart Failure: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Circulation 2006; 113:2201.
  3. Williams, , et al. Differential Impact of Blood Pressure Lowering Drugs on Central Aortic Pressure and Clinical Outcomes: Principal Results of the Conduit Artery Function Evaluation Study (CAFE). Circulation 2006; 113:1213.
  4. Verdecchia, et al. Angiotensin-converting enzyme inhibitors and calcium channel blockers for coronary heart disease and stroke prevention. Hypertension 2005; 46:386.
  5. Bosch, J, et al. Effect of Ramipril on the Incidence of Diabetes. New England Journal of Medicine 2006; 355:1551.
  6. Cooper, WO, Hernandez-Diaz, S, Arbogast, PG, et al. Major Congenital Malformations After First-Trimester Exposure to ACE Inhibitors. New England Journal of Medicine 2006; 354:2443.

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