A healthcare provider will take several factors into account when determining which antihypertensive drug should be tried first. In addition to considering the effectiveness and potential side effects, he or she will consider the person’s general health, sex, age, and race; the severity of the high blood pressure; any additional, underlying medical conditions; and whether particular drugs should not be used.

Certain antihypertensive drugs are specifically recommended for the treatment of particular conditions, even if the person does not have high blood pressure. In many cases, a person with one of these conditions also has high blood pressure. As examples:

An angiotensin-converting enzyme (ACE) inhibitor is recommended for people with diabetes mellitus who have increased levels of protein in the urine (proteinuria), heart failure, or a prior heart attack. (See “Patient education: Preventing complications in diabetes mellitus (Beyond the Basics)”.)

Beta blockers are recommended for people with heart failure or a prior heart attack. (See “Patient education: Heart failure (Beyond the Basics)” and “Patient education: Heart attack recovery (Beyond the Basics)”.)

Beta blockers or calcium channel blockers are recommended to control symptoms in people with angina pectoris, which is temporary chest pain caused by an inadequate oxygen supply to heart muscle in patients with coronary artery disease. (See “Patient education: Medications for angina (Beyond the Basics)”.)

There are also certain antihypertensive agents that are not recommended in some people. Some examples include:

ACE inhibitors and angiotensin II receptor blockers (ARBs) (and many other medications not used to treat high blood pressure) are not recommended during pregnancy.

Diuretics can worsen gout. (See “Patient education: Gout (Beyond the Basics)”.)

Thus, it is important to mention all current and previous medical problems to the healthcare provider to determine which medication is best.

Hypotension and meds

Orthostatic hypotension is an infrequent adverse effect of most of the drugs in current use in the treatment of hypertension; it is, however, more common with alpha 1-blockers (first dose), adrenergic blockers and centrally acting drugs. Sudden loss of blood volume, or excess diuresis, may precipitate orthostatic hypotension in any hypertensive patient. Drugs used for the treatment of psychiatric illnesses are all associated with a significant incidence of orthostatic hypotension: phenothiazines, tricyclic antidepressants and monoamine oxidase inhibitors. Cardiovascular drugs associated with hypotension include dopamine agonists, antianginals and antiarrhythmics.