Selection Of An Antihypertensive Agent

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The following section outlines therapies for hypertensive emergency and urgency. For those patients in an ambulatory setting, Table53:2. summarizes guidelines for the selection of an antihypertensive agent for patients with various coexisting conditions. 14 Diuretics should be one of the agents of first choice in patients with renal disease and congestive heart failure who are judged to be volume overloaded. Because of their greater prevalence of stage 3 hypertension (systolic pressure of 180 mmHg or more, and diastolic pressure of 110 mmHg or more), African American patients may require multidrug therapy. For treatment of patients with angina pectoris or postmyocardial infarction, b blockers are indicated. They are also indicated for those patients with a history of migraines, atrial fibrillation with rapid ventricular response, paroxysmal supraventricular tachycardia, and senile tremor. The use of b blockers is safe in the latter part of pregnancy, but their use should be avoided in early pregnancy because of an association with fetal growth retardation. Angiotensin-converting enzyme (ACE) inhibitors should be used in patients with congestive heart failure and can also be used in patients with a history of diabetes mellitus, especially those with diabetic nephropathy. The use of ACE inhibitors should be avoided in pregnant women. In the elderly, diuretics are the first choice for antihypertensive therapy because the pathophysiology of their hypertension is usually related to total peripheral resistance rather than cardiac output. b blockers are also recommended as alternative therapy. Use of agents that cause significant orthostatic changes (e.g., calcium-channel blockers, peripheral adrenergic blockers, and a blockers), as well as drugs that cause cognitive dysfunction (e.g., central a ; agonist), should be avoided in the elderly.

TABLE 53-2 Antihypertensive Treatment Regimens for Specific Populations

AGENTS FOR TREATMENT OF HYPERTENSIVE EMERGENCIES

Agents used in hypertensive emergencies are shown in Tabie53:3.

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