Patients with coronary artery disease or hypertension should not use which class of drugs

Alpha-2-agonists (eg, methyldopa, clonidine, guanabenz, guanfacine) stimulate alpha-2-adrenergic receptors in the brain stem and reduce sympathetic nervous activity, lowering blood pressure (BP). Because they have a central action, they are more likely than other antihypertensives to cause drowsiness, lethargy, and depression; they are no longer widely used. Clonidine can be applied transdermally once a week as a patch; thus, it may be useful for nonadherent patients (eg, those with dementia).

Postsynaptic alpha-1-blockers (eg, prazosin, terazosin, doxazosin) are no longer used for primary treatment of hypertension because evidence suggests no reduction in mortality. Also, doxazosin used alone or with antihypertensives other than diuretics increases risk of heart failure. However, they may be used in patients who have prostatic hypertrophy and need a 4th antihypertensive or in people with high sympathetic tone (ie, with high heart rate and spiking blood pressures) already on the maximum dose of a beta-blocker.

A dry, irritating cough is the most common adverse effect, but angioedema Angioedema Angioedema is edema of the deep dermis and subcutaneous tissues. It is usually an acute but sometimes a chronic mast cell–mediated reaction caused by exposure to a drug (eg, angiotensin-converting... read more

Chronic Kidney Disease Chronic kidney disease (CKD) is long-standing, progressive deterioration of renal function. Symptoms develop slowly and in advanced stages include anorexia, nausea, vomiting, stomatitis, dysgeusia... read more

Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more

Renal Artery Stenosis and Occlusion Renal artery stenosis is a decrease in blood flow through one or both of the main renal arteries or their branches. Renal artery occlusion is a complete blockage of blood flow through one or... read more

Thiazide-type diuretics enhance the antihypertensive activity of ACE inhibitors more than that of other classes of antihypertensives. Spironolactone and eplerenone also appear to enhance the effect of ACE inhibitors.

Beta-blockers (see table Oral Beta-Blockers for Hypertension Oral Beta-Blockers for Hypertension

Peripheral Arterial Disease Peripheral arterial disease (PAD) is atherosclerosis of the extremities (virtually always lower) causing ischemia. Mild PAD may be asymptomatic or cause intermittent claudication; severe PAD... read more

Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more

Beta-blockers with intrinsic sympathomimetic activity (eg, acebutolol, pindolol) do not adversely affect serum lipids; they are less likely to cause severe bradycardia.

Long-acting nifedipine, verapamil, or diltiazem is used to treat hypertension, but short-acting nifedipine and diltiazem are associated with a high rate of myocardial infarction and are not recommended.

Aliskiren, a direct renin inhibitor, is used in the management of hypertension. Dosage is 150 to 300 mg orally once a day, with a starting dose of 150 mg.

Direct vasodilators, including minoxidil and hydralazine (see table Direct Vasodilators for Hypertension Direct Vasodilators for Hypertension

• Loop diuretics

• Potassium-sparing diuretics

• Thiazide-type diuretics

Diuretics modestly reduce plasma volume and reduce vascular resistance, possibly via shifts in sodium from intracellular to extracellular loci.

Loop diuretics are used to treat hypertension only in patients who have lost > 50% of kidney function; these diuretics are given at least twice a day (except for torsemide which can be given once a day).

Thiazide-type diuretics are most commonly used. In addition to other antihypertensive effects, they cause a small amount of vasodilation as long as intravascular volume is normal. All thiazides are equally effective in equivalent doses; however, thiazide-type diuretics have longer half-lives and are relatively more effective at similar doses. Thiazide-type diuretics can increase serum cholesterol slightly (mostly low-density lipoprotein) and also increase triglyceride levels, although these effects may not persist > 1 year. Furthermore, levels seem to increase in only a few patients. The increase is apparent within 4 weeks of treatment and can be ameliorated by a low-fat diet. The possibility of a slight increase in lipid levels does not contraindicate diuretic use in patients with dyslipidemia Dyslipidemia Dyslipidemia is elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein cholesterol level that contributes to the development of atherosclerosis... read more

All diuretics except the potassium-sparing distal tubular diuretics cause significant potassium loss, so serum potassium is measured monthly until the level stabilizes. Unless serum potassium is normalized, potassium channels in the arterial walls close and the resulting vasoconstriction makes achieving the blood pressure (BP) goal difficult. Patients with potassium levels < 3.5 mEq/L (< 3.5 mmol/L) are given potassium supplements. Supplements may be continued long-term at a lower dose, or a potassium-sparing diuretic (eg, daily spironolactone 25 to 100 mg, triamterene 50 to 150 mg, amiloride 5 to 10 mg) may be added. Potassium supplements or addition of a potassium-sparing diuretic is also recommended for any patients who are also taking digitalis, have a known heart disorder, have an abnormal ECG, have ectopy or arrhythmias Overview of Arrhythmias The normal heart beats in a regular, coordinated way because electrical impulses generated and spread by myocytes with unique electrical properties trigger a sequence of organized myocardial... read more