Antihypertensive Choice

For people over the age of 80yrs use the same as people age 55-80yrs.

BAC = Black people of African or Carribean Descent

Examples of individual drugs are just a few- there are many more in each class.

Step 1 Treatment

Under 55yrs & Non-BAC

  • Angiotensin Converting Enzyme Inhibitor (ACE-I) Check U&Es before and 1-2wks after starting Ramipril
    • Perindopril
    • Lisinopril
    • Captopril


  • Angiotensin II Receptor Blocker (ARB) Candesartan
    • Losartan
    • Valsartan

Don’t combine ARB and ACE-I

If ACE-i is not tolerated due to for example cough – then treat with ARB.

Over 55yrs or BAC (any age)

  • Calcium Channel Blocker
    • Amlodipine
    • Diltazem
    • Felodipine
    • Nifedipine
    • Verapamil
  •  If Calcium channel Blocker is not suitable eg…
    • oedema
    • intolerence
    • heart failure or high risk of heart failure…
  • then….
  • offer a thiazide – like diuretic
    • eg…
    • Indapamide (1.25mg Modified Release once daily or 2.5mg Once Daily)
    • Chlortalidone (12.5 -25mg once daily)
    • These are preferable to conventional thiazide diuretics (bendroflumethiazide or hydrochlorothiazide)

If they’re already on bendroflumethiazide or hydrochlorothiazide and they’re stable – leave it be.

Step 2 Treatment

If not controlled by Step 1 alone

  • Add a CCB with ACE or ARB
  • If CCB not suitable use Thiazide like diuretic (indapamide)
  • CCB is not suitable when it’s not tolerated (leg swelling) or if they’re high risk of heart failure
  • If black/afrocarribean – use ARB over ACE-I

Step 3 Treatment

  • make sure compliance is good and everything is optomised
  • Combine the ACE-I/ARB with a CCB and a thiazide like diuretic

Step 4 Treatment

  • Add spironolactone
  • If that doesn’t work refer

The Amazing Antihypertensive Rap

  • “If white and young and need a pill,
  • take and ACE inhibitor like Ramipril
  • But if you need a different plan
  • Get an ARB like candesartan
  • It’ll only ever blow up in your face
  • If you combine the ARB with the ACE”

  • Verapamil, Amlodipine,
  • Nifedipine, Felodipine
  • In heart failure do not use them
  • They’re all CCBs – like diltazem
  • “Now here’s a rhyme from the back of the locker,
  • The old or black get a calcium channel blocker
  • If they don’t get along, don’t go thiazide,
  • Give a something like one – indapamide”

  • Verapamil, Amlodipine,
  • Nifedipine, Felodipine,
  • In heart failure, do not use them
  • They’re all CCBs – like diltiazem
  • Step Two comes next with a CCB
  • added to the ACE or the ARB
  • Again if the blocker don’t get a tick
  • Add indapamide, a thiazide-like diuretic
  • If they’re afro-carribean, they’ve got a black face
  • Use an ARB rather than an ACE

  • Verapamil, Amlodipine,
  • Nifedipine, Felodipine
  • In heart failure, do not use them
  • They’re all CCBs – like diltiazem
  • Check Compliance then step 3
  • Combine the other two with the TLD
  • Step 4’s so simple there’s no need to moan
  • But call for help after spironolactone

Nice Hypertension guidance