Drugs in hypertension
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Drug Treatments for Hypertension: An Overview
First-Line Antihypertensive Drugs: Efficacy and Safety
Thiazide Diuretics
Thiazide diuretics, particularly at low doses, are highly effective as first-line treatments for hypertension. They significantly reduce mortality, total cardiovascular events (CVS), stroke, and coronary heart disease (CHD) compared to placebo or no treatment. High-dose thiazides also reduce stroke and total CVS but do not significantly impact mortality or CHD. However, both low- and high-dose thiazides are associated with increased withdrawals due to adverse effects.
ACE Inhibitors
ACE inhibitors are another effective first-line treatment, reducing mortality, stroke, CHD, and total CVS. They are comparable to thiazides in terms of efficacy but have a lower quality of evidence supporting their use. ACE inhibitors also show a slight reduction in stroke when compared directly with thiazides.
Calcium Channel Blockers
Calcium channel blockers reduce stroke and total CVS but do not significantly impact mortality or CHD. They are less effective than thiazides in reducing heart failure but are associated with fewer withdrawals due to adverse effects.
Beta-Blockers
Beta-blockers reduce stroke and total CVS but do not significantly impact mortality or CHD. They are less effective than thiazides and are associated with a higher rate of withdrawals due to adverse effects.
Alpha-Blockers and ARBs
There is limited evidence for the efficacy of alpha-blockers and angiotensin II receptor blockers (ARBs) as first-line treatments due to a lack of randomized controlled trials (RCTs). However, alpha-blockers may reduce total cardiovascular events and heart failure when compared to thiazides.
Dual Combination Therapy
Dual combination therapy, using two antihypertensive drugs at low-to-standard doses, is more effective in reducing systolic blood pressure (SBP) and improving blood pressure control compared to monotherapy. This approach does not significantly increase withdrawals due to adverse events, making it a viable option for initial treatment.
Hypertension in Older Adults
In adults aged 60 years or older, antihypertensive drug treatment, primarily with thiazides, reduces all-cause mortality, cardiovascular morbidity and mortality, cerebrovascular morbidity and mortality, and CHD morbidity and mortality. The benefits are more pronounced in the 60-79 age group compared to those 80 years or older.
Emerging Drug Classes
New drug classes are being developed to address the limitations of current antihypertensive treatments. These include dual angiotensin II receptor-neprilysin inhibitors, soluble guanylate cyclase stimulators, and nonsteroidal dihydropyridine-based mineralocorticoid receptor antagonists. These emerging drugs aim to improve blood pressure control and reduce cardiovascular risks further.
Conclusion
Thiazide diuretics, ACE inhibitors, and calcium channel blockers are effective first-line treatments for hypertension, with thiazides showing the most robust evidence for reducing mortality and morbidity. Dual combination therapy offers an effective alternative to monotherapy, and new drug classes hold promise for future treatment options. For older adults, antihypertensive treatment significantly reduces mortality and cardiovascular events, particularly with thiazides. Continued research and development of new antihypertensive drugs are essential to improve treatment outcomes and address the global burden of hypertension.
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