CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 1, February 2012
AFRICA
55
patients. Equally, uncomplicated essential
hypertension (those at low and moder-
ate risk) is dealt with according to these
guidelines, with treatment using three
antihypertensive agents – thiazide and
thiazide-like diuretics, ACE inhibitors
(ACEI) and angiotensin receptor blockers
(ARBs), and calcium channel blockers
(CCBs). This simplifies the primary-care
guideline for patients in this category.
At the heart of these guidelines there-
fore, is the list of clinical considerations
and possible contra-indications of the
major antihypertensive drug groups. The
JNC-7 (2003) summarises compelling
indications for individual drug classes
according to the indication (Table 3).
The South African guidelines treat
compelling indications (and contra-indi-
cations) according to the class of drug,
perhaps not as easy a clinical reference as
the JNC-7 (Table 4).
Combination therapy
The new guidelines note that combina-
tion therapy should be considered from
the outset if the blood pressure is
≥
20/10 mmHg above goal and there are
co-morbidities to consider such as diabe-
tes, isolated systolic hypertension (ISH),
chronic kidney disease (CKD) or overt
cardiovascular disease. Also the guide-
lines note that the combination of thiazide
or thiazide-like diuretic with
β
-blockers
should not be used in uncomplicated
essential hypertension with abdominal
obesity, as both classes of drugs have
adverse metabolic consequences. The
report notes that black patients respond
best to diuretics or CCBs combined with
other anti-hypertensive agents.
Specific situations
The guidelines also deal with the manage-
TABLE 3. COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES
Compelling indication
Initial therapy options
Heart failure
(Thiazide, BB, ACEI, ARB, aldosterone antagonist)
Post MI
(BB, ACEI, aldosterone antagonist)
High CVD risk
(Thiazide, BB, ACEI, CCB)
Diabetes
(Thiazide, BB, ACEI, ARB, CCB)
Chronic kidney disease
(ACEI, ARB)
Recurrent stroke prevention
(Thiazide, ACEI)
Amended pg 33, JNC-7. MI, myocardial infarction; BB,
β
-blockers
TABLE 4. INDICATIONSAND CONTRA-INDICATIONS FOR THE MAJOR CLASS OFANTIHYPERTENSIVE DRUGS*
Class
Conditions following use
Contra-indications compelling
Contra-indications possible
ACEIs
Heart failure
Left ventricular dysfunction
Post-myocardial infarction
Non-diabetic nephropathy
Type 1 diabetic nephropathy
Prevention of diabetic microalbuminuria
Proteinuria
Pregnancy
Hyperkalaemia
Bilateral renal artery stenosis
Angioneurotic oedema (more common
in blacks than whites)
ARBs
Type 2 diabetic nephropathy
Type 2 diabetic microalbuminuria
Non-diabetic nephropathy
Left ventricular hypertrophy
ACEI cough or intolerance
Patients at high CV risk
Pregnancy
Hyperkalaemia
Bilateral renal artery stenosis
β
-blockers
Angina pectoris
Post-myocardial infarction
Heart failure (selected)
Tachyarrhythmias
Asthmas
Chronic obstructive pulmonary disease
Atrio-ventricular block (grade 2 or 3)
Pregnancy (atenolol)
Peripheral vascular disease
Bradycardia
Glucose intolerance
Metabolic syndrome
Athletes and physically active patients
Non-dihydropyridine CCBs
(verapamil, diltiazem)
CCB
Long-acting only
(dihydropyridine)
Elderly patients
Isolated systolic hypertension
Angina pectoris
Peripheral vascular disease
Carotid atherosclerosis
Pregnancy (nifedipine only)
Tachyarrhythmias
Heart failure
Diuretics (anti-aldo-
sterone)
Heart failure
Post-myocardial infarction
Resistant hypertension
Renal failure
Hyperkalaemia
Diuretics (loop)
Renal insufficiency
Heart failure
Pregnancy
Diuretics (thiazide/
thiazide-like)
Heart failure
Elderly hyptensives
Isolated systolic hypertension
Hypertensives of African origin
Gout
Preganancy
β
-blockers (especially atenolol)
Non-dihydropyridine
CCB (verapamil,
diltiazem)
Angina pectoris
Carotid atherosclerosis
Supraventricular tachycardia
Atrio-ventricular block (grade 2 or 3)
Heart failure
Constipation (verapamil)
*Adapted from the JNC-7 guidelines
