TABLE 8.

Considerations in the individualization of antihypertensive therapy

	Initial therapy	Second-line therapy	Notes and/or cautions
Hypertension without compelling indications for other medications
Diastolic ± systolic hypertension	Thiazide diuretic, beta-blocker (for patients younger than 60 years of age), ACE inhibitor (in nonblack patients), ARB or long-acting CCB	Combinations of first-line drugs	Initial monotherapy should not include alpha-blockers, beta-blockers in patients 60 years of age or older, or ACE inhibitors in black patients. Hypokalemia should be avoided in those who are prescribed diuretics. Caution should be exercised in combining a nondihydropyridine CCB and a beta-blocker
Isolated systolic hypertension	Thiazide diuretic, ARB or long-acting dihydropyridine CCB	Combinations of first-line drugs	Similar cautions as in diastolic ± systolic hypertension without compelling indications
Global vascular protection therapy	Statin therapy (for patients with 3 or more cardiovascular risk factors or atherosclerotic disease). Low-dose ASA therapy		Caution should be exercised in using ASA if blood pressure is not controlled
Coronary artery disease	Beta-blocker (for patients with stable angina); ACE inhibitor (for most patients)	Long-acting CCB	Avoid short-acting nifedipine
Prior myocardial infarction	Beta-blocker and ACE inhibitor	An ARB may be used if ACE inhibitor-intolerant and left ventricular dysfunction is present. Long-acting CCB if beta-blocker is contraindicated or not effective	Avoid nondihydropyridine CCBs if heart failure also present
Heart failure	ACE inhibitor and beta-blocker; aldosterone antagonist (in selected patients)	ARB if ACE inhibitor-intolerant, hydralazine/isosorbide dinitrate if ACE inhibitor- and ARB-intolerant; if blood pressure not controlled, an ARB may be added to ACE inhibitor. Thiazide or loop diuretics as additive therapy. Long-acting dihydropyridine CCB as additive therapy	If combining an ACE inhibitor and an ARB, monitor for potential adverse events, including hypotension, hyperkalemia and worsening renal function
Cerebrovascular disease	ACE inhibitor/diuretic combination		Caution is indicated in deciding whether to lower blood pressure in the acute stroke situation; pharmacological agents and routes of administration should be chosen to avoid precipitous falls in blood pressure
Left ventricular hypertrophy	ACE inhibitor, ARB, long-acting CCB or thiazide diuretic		Avoid direct arterial vasodilators such as hydralazine and minoxidil
Nondiabetic chronic kidney disease
Nondiabetic chronic kidney disease	ACE inhibitors (for patients with proteinuria*)	ARB if ACE inhibitor-intolerant. Thiazide diuretic as additive antihypertensive therapy; loop diuretics for volume overload	Avoid ACE inhibitors and ARBs if bilateral renal artery stenosis or unilateral disease with solitary kidney
Renovascular disease	Similar to diastolic ± systolic hypertension without compelling indications for other medications		Avoid ACE inhibitors and ARBs if bilateral renal artery stenosis or unilateral disease with solitary kidney
Diabetes mellitus
Diabetes mellitus without albuminuria	ACE inhibitor, ARB, thiazide diuretic or dihydropyridine CCB	If these drugs are not tolerated, a cardioselective beta-blocker or nondihydropyridine CCB may be used	Avoid alpha-blockers as initial monotherapy
Diabetes mellitus with albuminuria†	ACE inhibitor or ARB	Additional antihypertensive agents should be used to achieve target blood pressures	Avoid alpha-blockers as initial monotherapy

^*Proteinuria is defined as urinary protein >500 mg/24 h or albumin to creatinine ratio >30 mg/mmol;

^†Albuminuria is defined as persistent albumin to creatinine ratio >2.0 mg/mmol in men and >2.8 mg/mmol in women. ACE Angiotensin-converting enzyme; ARB Angiotensin receptor blocker; ASA Acetylsalicylic acid; CCB Calcium channel blocker. Reproduced with permission of the Canadian Hypertension Education Program