Which Antihypertensive Drugs First— and Why!

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Abstract
PREVENTION of cardiovascular disease and extension of life are the goals of antihypertensive treatment. These objectives have been convincingly achieved in clinical trials using diuretic and βblockade therapy.1,2Now, however, an expansion of therapeutic options has created a practical dilemma. Clinicians must select hypotensive therapy that properly balances the hard knowledge gained from clinical trials with reasonable hopes raised by new drugs with important theoretical advantages. It was not always so. Twenty years ago, treatment decisions were rather simple. Diuretics, guanethidine, reserpine, hydralazine, and methyldopa were the available and approved choices. In the Veterans Administration (VA) study, diuretics and reserpine had been the basic agents.3Initial consensus recommendations were to begin drug therapy with a diuretic, adding second or third drugs as needed to attain blood pressure control.4 No less than 13 large controlled trials thereafter confirmed and extended the conclusions drawn from the VA trial.1,2

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