ACE inhibitors, calcium channel blockers, thiazides, then spironolactone or beta blockers
Mnemonic
“ACD”, the UK stepwise approach:
- A - ACE inhibitor or Angiotensin receptor blocker
- C - Calcium channel blocker
- D - thiazide-like Diuretic (indapamide)
Step 1: A if under 55 or diabetic; C if over 55 or of black African or Caribbean family origin, in whom renin levels are lower.
Step 2: A + C (or A + D). Step 3: A + C + D.
Step 4, resistant hypertension: add spironolactone if potassium is 4.5 or below, or an alpha or beta blocker if above.
“A for the young, C for the old, and never A alone in the black African population.”
Beta blockers are no longer first line for uncomplicated hypertension, but remain indicated with angina, heart failure or after infarction. ACE inhibitors and ARBs are contraindicated in pregnancy, where labetalol, nifedipine and methyldopa are used.
Expansion
| Class | Examples | Key adverse effects |
|---|---|---|
| ACE inhibitors | Ramipril, lisinopril | Dry cough (bradykinin), hyperkalaemia, angioedema, renal impairment, teratogenic |
| Angiotensin receptor blockers | Losartan, candesartan | As above but no cough |
| Calcium channel blockers | Amlodipine (dihydropyridine) | Ankle oedema, flushing, headache |
| Verapamil, diltiazem (rate limiting) | Bradycardia, constipation; never with a beta blocker | |
| Thiazide-like diuretics | Indapamide, bendroflumethiazide | Hyponatraemia, hypokalaemia, gout, hyperglycaemia |
| Spironolactone | Hyperkalaemia, gynaecomastia | |
| Beta blockers | Bisoprolol | Fatigue, bradycardia, bronchospasm, masks hypoglycaemia |
| Alpha blockers | Doxazosin | Postural hypotension |
Stepwise approach
- Step 1: ACE inhibitor or ARB if under 55 or diabetic; calcium channel blocker if over 55 or of African or Caribbean family origin, where renin levels are typically lower
- Step 2: combine the two
- Step 3: add a thiazide-like diuretic
- Step 4 (resistant hypertension): spironolactone if potassium is 4.5 or below, otherwise an alpha or beta blocker
Verapamil with a beta blocker is the combination to avoid absolutely, since both slow the atrioventricular node and can cause complete heart block or asystole.