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Arterial hypertension: second-line treatment

FEATURED REVIEW Reliable evidence supports the use of thiazide diuretics as first-line treatment for uncomplicated arterial hypertension. When patients fail to reach blood pressure targets, or this treatment is poorly tolerated, what are the best second-line options? We reviewed the available evidence, based on our standard in-house methodology.
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Abstract

  • Reliable evidence supports the use of thiazide diuretics (chlortalidone or hydrochlorothiazide) as first-line treatment for uncomplicated arterial hypertension.
  • When patients fail to reach blood pressure targets with well-conducted treatment with thiazide diuretics, or this treatment is poorly tolerated, what are the best second-line options? To answer this question, we reviewed the available evidence, based on our standard in-house methodology.
  • We found no published trials specifically designed to evaluate second-line antihypertensive treatments in cardiovascular prevention.There were no available trials of dual- versus singleagent therapy after failure of a thiazide diuretic.
  • When the blood pressure target is not reached, inadequate drug efficacy is only one of several possible causes. Various other factors affecting blood pressure should also be investigated.
  • Dual-agent therapy carries an increased risk of adverse effects and drug interactions compared to monotherapy.
  • There is no consensus among clinical practice guidelines on second-line antihypertensive therapy.However, to minimise the risk of adverse effects, it is clearly better to select single-agent therapy with a drug that has been shown to prevent cardiovascular events in first-line treatment of otherwise healthy hypertensive patients.Possible options include: angiotensin-converting- enzyme inhibitors, angiotensin II antagonists, calcium channel blockers or betablockers. In patients over the age of 60, betablockers seem less effective than the other drugs in preventing