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Principles of Heart Failure Pharmacotherapy
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Erika L. Hellenbart, Stephanie Dwyer Kaluzna, Robert J. DiDomenico
Several thiazide-like diuretics have been studied as part of sequential nephron blockade and their efficacy is considered a class effect; superiority of a single agent, including IV chlorothiazide, has not been demonstrated.72–74 Therefore, equipotent doses of any thiazide-like diuretic (Table 5.4) should be effective. Chlorothiazide has the shortest half-life and, along with hydrochlorothiazide, has the shortest duration of action (<24 hours; Table 5.4).75 In contrast, the half-lives of bendroflumethiazide, indapamide, and metolazone are longer and their effects can persist for 36–48 hours, particularly in patients with CKD.72,75,76
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Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
Hypertension is a major risk factor for ischaemic heart disease, stroke, chronic kidney disease, heart failure and many more. Deciding when to start treatment for this can be difficult. Current guidelines suggest starting treatment on all patients with a sustained blood pressure ≥ 160/100 mmHg. In patients whose blood pressure is not quite this high, but is ≥ 140/90, other cardiac risk factors should be assessed and a decision made in conjunction with the patient regarding whether to start antihypertensive medication. ACE inhibitors are first-line drugs in those < 55 who are not of Affo-Carribean descent. Those of Afro-Carribean descent or those >55 are now treated with a calcium channel blocker (CCB) first-line. NICE guidelines regarding hypertension were changed slighdy in August 2011. Previously, guidelines stated that a CCB or a thiazide diuretic could be used first-line in those of Afro-Carribean descent or in those >55. Diuretics are no longer first-fine, although they should be used if there are contraindications to starting a CCB. Also, the diuretic of choice was previously a thiazide diuretic, such as bendroflumethiazide. This has now changed to a thiazide-like diuretic, such as indapamide or chlortalidone. Patients already established on a thiazide diuretic and whose hypertension is well controlled should continue this.
Hypertension
Published in Swati Gupta, Alexandra Marsh, David Dunleavy, Kevin Channer, Cardiology and the Cardiovascular System on the move, 2015
Swati Gupta, Alexandra Marsh, David Dunleavy, Kevin Channer
Step 1 Treatment (see Figure 10.2) For people aged under 55 years: ACE inhibitor (ACEi) orLow-cost angiotensin II receptor blockers (ARB) if an ACEi is not toleratedPeople aged over 55 years and for people of Afro-Caribbean origin of any age: Calcium channel blocker (CCB) orThiazide-like diuretic if any of the following: – CCB is not suitable.– Evidence of heart failure.– High risk of heart failure.If treatment with a diuretic is being started, or changed, offer a thiazide-like diuretic, such as indapamide.
Safety implications of combining ACE inhibitors with thiazides for the treatment of hypertensive patients
Published in Expert Opinion on Drug Safety, 2020
Claudio Borghi, Mario Soldati, Alessio Bragagni, Arrigo F.G Cicero
Hypertension is the most important risk factor for cardiovascular disease and his treatment relies on the use of effective antihypertensive dugs given as monotherapy or, more frequently, as combinations of two or more complementary drugs. ACE-inhibitors and diuretics are widely used for the treatment of high blood pressure and their combination (particularly singe-pill combination) has proven to be very effective by improving blood pressure control and reducing the rate of major cardiovascular complications in a large population of hypertensive patients with different levels of cardiovascular risk. The clinical efficacy of the combination of ACEi and diuretic has been tested in several large randomized clinical trials involving patients with and without previous cardiovascular disease reporting a reduction a generalized improvement in the clinical outcome (mortality and morbidity). The cardiovascular benefit has been reported to be lesser than that observed with the combination of ACEI and CCBs. The most significant results have been observed in patients where the ACEi has been combined with the thiazide-like diuretic IND bearing some additional pharmacological properties that can significantly contribute to cardiovascular prevention. Overall, the clinical efficacy of the combination of ACEi and diuretic is associated with a safe tolerability profile, even in comparison to the other possible first-line combinations for the treatment of hypertension (ACEI and CCBs) and this suggest a high benefit/risk ratio and promotion of adherence to treatment that can result of primary importance for the management of hypertension.
Treatment strategies for hypertension in patients with type 1 diabetes
Published in Expert Opinion on Pharmacotherapy, 2020
Alexandra Katsimardou, Konstantinos Imprialos, Konstantinos Stavropoulos, Alexandros Sachinidis, Michalis Doumas, Vasilios G. Athyros
Similarly, another field for further research could be the antihypertensive treatment in grade 1 hypertension in this population. Should we start with monotherapy or with a two-drug combination as initial pharmacotherapy? There are no trials concerning this matter for T1DM patients. Furthermore, regarding the two-drug combination therapy, the inclusion of RAS blockers in the initial therapeutic regimen is already proposed by most scientific societies as previously mentioned, due to their positive effects on microvascular and macrovascular diabetic complications. However, there are no trials assessing whether the addition of a CCB is superior to the addition of a thiazide/thiazide-like diuretic or vice-versa. In the absence of solid evidence, the use of a single pill with a two-drug combination of an ACEi or an ARB with a CCB or a thiazide/thiazide-like diuretic as initial pharmacotherapy is strongly advised, as non-adherence to treatment is a major concern and can be possibly minimized with simpler therapeutic instructions.
Combination therapies for hypertension – why we need to look beyond RAS blockers
Published in Expert Review of Clinical Pharmacology, 2018
Manuel Gorostidi, Alejandro de la Sierra
As stated, the rationale for combining antihypertensive drugs relates to the additive BP-lowering effect when two different classes are administered simultaneously, and to the capacity of minimizing the counter-regulatory mechanisms triggered by the initiation of a pharmacologic intervention. The compensatory rise in renin activity induced by the sodium depletion related to diuretic therapy may limit the BP-lowering effect of these drugs. Simultaneous blockade of the renin–angiotensin system, with either an ACE inhibitor or an ARB, counteracts this compensatory mechanism. The combination of a diuretic with an ACE inhibitor or an ARB is the most widely used two-drug antihypertensive treatment. The vast majority of outcome trials involving an ACE inhibitor or an ARB as active therapy used diuretics as add-on strategy. Last examples were ADVANCE (Action in diabetes and vascular disease; Preterax and Diamicron-MR controlled evaluation) [56], and HYVET (Hypertension in the very elderly trial) [57]. In ADVANCE, the combination of an ACE inhibitor and a thiazide-like diuretic given to patients with type 2 diabetes reduced the incidence of diabetes-related complications. In HYVET, the administration of the same combination conferred lower rates of cardiovascular events.