·   Some Considerations for Choosing Treatments (unless otherwise contraindicated).

• Pregnancy
  • If taken before pregnancy, most antihypertensives can be continued except ACE inhibitors and angiotensin II receptor blockers.
  • Methyldopa is most widely used when hypertension is detected during pregnancy.
  • Beta-Blockers are not recommended early in pregnancy.
• African Americans
  • Diuretics have been demonstrated to decrease morbidity and mortality, and hence should be first choice.
  • Ca++ blockers and alpha/beta blockers are effective.
  • Patients may not respond well to monotherapy with beta-blockers or ACE inhibitors.
• Elderly
  • Smaller doses, slower incremental increases in dosing, and simple regimens should be used.
  • Close monitoring for side effects (i.e., deficits in cognition after methyldopa; postural hypotension after prazosin) is appropriate.
• Diabetes mellitis
  • ACE inhibitors, alpha-antagonists, and calcium antagonists can be effective, and have few adverse effects on carbohydrate metabolism.
• Hyperlipidemic
  • Low dose diuretics have little effect on cholesterol and triglycerides.
  • Alpha-Blockers decrease LDL/HDL ratio. Calcium-channel blockers, ACE inhibitors, angiotensin II receptor blockers have little effect on lipid profile.
• Obstructive airway disease
  • Avoid beta-blockers.

* Investigations commonly performed in newly diagnosed hypertension

Tests are undertaken to identify possible causes of secondary hypertension, and seek evidence for end-organ damage to the heart itself or the eyes (retina) and kidneys. Diabetes and raised cholesterol levels being additional risk factors for the development of cardiovascular disease are also tested for as they will also require management.

Blood tests commonly performed include:

·   Creatinine (renal function) - to identify both underlying renal disease as a cause of hypertension and conversely hypertension causing onset of kidney damage. Also a baseline for later monitoring the possible side-effects of certain antihypertensive drugs.

·   Electrolytes (sodium, potassium)

·   Glucose - to identify diabetes mellitus

·   Cholesterol

Additional tests often include:

·   Testing of urine samples for proteinuria - again to pick up underlying kidney disease or evidence of hypertensive renal damage.

·   Electrocardiogram (EKG/ECG) - for evidence of the heart being under strain from working against a high blood pressure. Also may show resulting thickening of the heart muscle (left ventricular hypertrophy) or of the occurrence of previous silent cardiac disease (either subtle electrical conduction disruption or even a myocardial infarction).

·   Chest X-ray - again for signs of cardiac enlargement or evidence of cardiac failure

* Distinguishing primary vs. secondary hypertension

Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify reversible (secondary) causes.

·                     Over 90% of adult hypertension has no clear cause and is therefore called essential/primary hypertension. Often, it is part of the metabolic "syndrome X" in patients with insulin resistance: it occurs in combination with diabetes mellitus (type 2), combined hyperlipidemia and central obesity.

·                     In hypertensive children most cases are secondary hypertension, and the cause should be pursued diligently.