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Therapeutics · Cardiovascular

Hypertension

Therapeutic goals

  • Lower long-term cardiovascular and renal risk, not just today's number
  • Reach the individualized target with the fewest tolerable agents
  • Protect adherence: once-daily regimens and single-pill combinations where possible

Patient factors that steer the choice

  • Age and frailty (orthostatic risk)
  • Diabetes or proteinuric CKD (RAAS blockade earns priority)
  • Pregnancy or pregnancy potential (RAAS blockade leaves the list)
  • Ancestry and guideline context for first-line choice
  • NSAID use, salt substitutes, and OTC decongestants: the silent saboteurs

Major drug classes

ACE inhibitorsAngiotensin receptor blockersCalcium channel blockersThiazide diureticsBeta blockers

Treatment approach

  1. 01Confirm and stage

    Out-of-office measurements confirm the diagnosis; secondary causes get one deliberate thought (renal, endocrine, drug-induced: including NSAIDs and stimulants).

  2. 02Start with a first-line class

    ACE inhibitor/ARB, dihydropyridine CCB, or thiazide; comorbidity picks among them (diabetes/CKD → RAAS blockade; angina → CCB or BB).

  3. 03Combine before maximizing

    Two half-dose agents beat one maximal dose on both efficacy and side effects; RAAS blocker + CCB or + thiazide are the natural pairs. Never ACE inhibitor + ARB.

  4. 04Escalate systematically

    Three-drug standard is RAAS + CCB + thiazide at optimized doses; resistant hypertension then asks about adherence, NSAIDs, and secondary causes before a fourth agent (classically spironolactone).

Monitoring

  • BP at home, properly measured
  • Creatinine and potassium after RAAS or diuretic changes
  • Ankle edema on CCBs
  • Adherence, at every refill

Pearls

  • The commonest cause of 'resistant hypertension' at the counter is ibuprofen.
  • A single-pill combination is an adherence intervention disguised as a prescription.

Choose the drug

Hypertension

58-year-old with newly confirmed hypertension (average 152/94 on home readings).

Type 2 diabetes with microalbuminuria. eGFR 74. Potassium 4.2.

No other medications; no allergies.

Which first agent fits this patient best?

Keep going

RAAS pathway →ACE inhibitors →The triple whammy →

Last reviewed 2026-08-15 · Principle-level content; jurisdiction-specific recommendations live in the cited guidelines: Hypertension Canada Guidelines (current edition) · 2023 ESH Guidelines for the management of arterial hypertension