Comorbidities that influence antihypertensive selection
THE CONTEXT
Coexisting disease can favour a drug class or require caution, contraindication checks and specialist supervision.
Adrenergic blockers
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Benign prostatic hypertrophy is a compelling indication for α-blockers. Cautions include postural hypotension and heart failure, with the heart failure qualification applying to monotherapy; urinary incontinence is a compelling contraindication.
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Myocardial infarction and angina are compelling indications for beta-blockers. The table lists asthma or chronic obstructive pulmonary disease and heart block as compelling contraindications.
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Beta-blockers are increasingly used in stable heart failure but may worsen acute heart failure.
ACE inhibitors and angiotensin receptor blockers
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Heart failure is a compelling indication for angiotensin-converting enzyme inhibitors. ACE inhibitor intolerance is a compelling indication for angiotensin II receptor blockers.
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Pregnancy is listed as a compelling contraindication for both classes.
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Both classes may benefit chronic renal failure and renovascular disease, but established significant renal impairment requires caution, close supervision and specialist advice.
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Peripheral arterial disease warrants caution with both classes because it is associated with renovascular disease.
Calcium channel blockers and diuretics
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Dihydropyridine calcium channel blockers have compelling indications in older patients and isolated systolic hypertension; peripheral oedema is a caution.
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Rate-limiting calcium channel blockers have a compelling indication in angina. Combination with beta-blockade requires caution; atrioventricular block and heart failure are compelling contraindications.
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Thiazides or thiazide-like diuretics have compelling indications in older patients, isolated systolic hypertension, heart failure and secondary stroke prevention.
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Although gout is listed as a compelling contraindication, thiazides or thiazide-like drugs may sometimes be necessary for blood pressure control in patients with a history of gout, ideally combined with allopurinol.