Students in their first graduate level pharmacology course are confused with the
recommendations for hypertension (HTN) and treatment choices after ST-elevation myocardial
infarction (STEMI) and with heart failure (HF). The drugs used several years ago and still seen
commonly on the acute care floors the students work are not the ones now assuming a stronger
role in cardiac health issues. For one, the primary order of which meds are selected for an initial
level of blood pressure control has seemed to change.
Help your fellow students by explaining the following changes.
1. Which classification of drugs has taken the first-choice role in most patients with early
hypertension? Is it wrong to select a thiazide diuretic or a beta blocker as was once done?
a. The Eighth Joint National Committee (JNC8) outlines the initial drug choices for
hypertension with regards to other comorbidities or race, etc, in their hypertension
guideline algorithm. The first choice drugs outlined by JNC8 for early
hypertension include ACE inhibitors, ARBs, CCB, and Thiazide diuretics
(Armstrong, 2014). For the general population of any age (excluding African
Americans), with no presence of diabetes or CKD, it is recommended to start any
of the previously listed 4 medications (Armstrong, 2014). And if hypertension
persists, it is recommended to increase the dose on the single medication, if
hypertension still persists, an addition of another one of the 4 drugs may be
necessary (Armstrong, 2014). For patients with diabetes and CKD (regardless of
race) it is recommended to initiate therapy with an ACE or ARB (Armstrong,
2014). The shift in these first line treatments comes from years of long term
controlled trials and research that suggests a reduced morbidity and mortality
related to hypertension when using these drugs (Burchum & Rosenthal, 2020).
These drugs are also very cost effective and generally well tolerated despite a few
exceptions (Burchum & Rosenthal, 2020). Other alternative drugs such as
beta-blockers (metoprolol) are often associated with high incidences of adverse
effects, or deemed not as effective for patients with certain conditions (Burchum
& Rosenthal, 2020). However, it is not wrong to select one of these previous first
line drugs for patients that it may benefit. For example, the JNC8 recommends for
patients post myocardial infarction to be started on an ACEI/ARB as well as a
beta blocker (Armstrong, 2014). Another example is the recommended treatment
for patients with CHF, this includes a ACEI/ARB, a beta blocker, and a diuretic
(Armstrong, 2014). Although first line treatment recommendations have changed
and should be followed as much as possible, it is always important to review the
patient as a whole, what their comorbidities are, lifestyle choices, family history,
etc, to pick which drug may work best for them.
recommendations for hypertension (HTN) and treatment choices after ST-elevation myocardial
infarction (STEMI) and with heart failure (HF). The drugs used several years ago and still seen
commonly on the acute care floors the students work are not the ones now assuming a stronger
role in cardiac health issues. For one, the primary order of which meds are selected for an initial
level of blood pressure control has seemed to change.
Help your fellow students by explaining the following changes.
1. Which classification of drugs has taken the first-choice role in most patients with early
hypertension? Is it wrong to select a thiazide diuretic or a beta blocker as was once done?
a. The Eighth Joint National Committee (JNC8) outlines the initial drug choices for
hypertension with regards to other comorbidities or race, etc, in their hypertension
guideline algorithm. The first choice drugs outlined by JNC8 for early
hypertension include ACE inhibitors, ARBs, CCB, and Thiazide diuretics
(Armstrong, 2014). For the general population of any age (excluding African
Americans), with no presence of diabetes or CKD, it is recommended to start any
of the previously listed 4 medications (Armstrong, 2014). And if hypertension
persists, it is recommended to increase the dose on the single medication, if
hypertension still persists, an addition of another one of the 4 drugs may be
necessary (Armstrong, 2014). For patients with diabetes and CKD (regardless of
race) it is recommended to initiate therapy with an ACE or ARB (Armstrong,
2014). The shift in these first line treatments comes from years of long term
controlled trials and research that suggests a reduced morbidity and mortality
related to hypertension when using these drugs (Burchum & Rosenthal, 2020).
These drugs are also very cost effective and generally well tolerated despite a few
exceptions (Burchum & Rosenthal, 2020). Other alternative drugs such as
beta-blockers (metoprolol) are often associated with high incidences of adverse
effects, or deemed not as effective for patients with certain conditions (Burchum
& Rosenthal, 2020). However, it is not wrong to select one of these previous first
line drugs for patients that it may benefit. For example, the JNC8 recommends for
patients post myocardial infarction to be started on an ACEI/ARB as well as a
beta blocker (Armstrong, 2014). Another example is the recommended treatment
for patients with CHF, this includes a ACEI/ARB, a beta blocker, and a diuretic
(Armstrong, 2014). Although first line treatment recommendations have changed
and should be followed as much as possible, it is always important to review the
patient as a whole, what their comorbidities are, lifestyle choices, family history,
etc, to pick which drug may work best for them.
