Rapid Review·Cardiovascular
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PHARMACOLOGY
T1Must knowHypertension Treatment By Comorbidity
P321
Focus on
The comorbidity picks the drug, and every pairing has a mechanistic reason.
Key takeaways
The comorbidity picks the drug
Primary (essential) hypertension
thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers.The whole logic of this page
the comorbidity picks the drug, and each pairing exists for a reason: protect the kidney, avoid the bronchospasm, avoid the teratogen, avoid the gout flare.Two drugs cut both ways
which is what makes them good exam material.- Thiazides help osteoporosis by increasing calcium reabsorption, but trigger gout by retaining urate.
- Beta-blockers help heart failure, but mask hypoglycemia in diabetes.
| Comorbidity | Drugs of choice | Why, and what to avoid |
|---|---|---|
| Primary (essential) | Thiazides, ACE inhibitors, ARBs, CCBs | Any first-line agent |
| Heart failure | ACE inhibitors or ARBs, beta-blockers in compensated HF, aldosterone antagonists (mortality benefit), diuretics (symptoms) | Beta-blockers cautiously in decompensated HF, contraindicated in cardiogenic shock; the ARB can be paired with sacubitril |
| Diabetes mellitus | ACE inhibitors or ARBs, CCBs, thiazides, beta-blockers | ACEi/ARBs protect against diabetic nephropathy; beta-blockers mask hypoglycemia |
| Asthma | ARBs, CCBs, thiazides, cardioselective beta-blockers | Avoid non-selective beta-blockers (beta-2 bronchoconstriction); avoid ACE inhibitors, whose cough confuses the picture |
| Pregnancy | Hydralazine, methyldopa, labetalol, nifedipine | "Hypertensive moms love nifedipine" (or "New Moms Love Hugs"). Avoid ACE inhibitors and ARBs, which are teratogenic |
| Gout | ACE inhibitors, CCBs, ARBs (especially losartan, which is uricosuric) | Avoid loop and thiazide diuretics, which precipitate flares |
| Osteoporosis | Thiazides preferred | They increase calcium reabsorption |
| Pheochromocytoma | Alpha-blockade FIRST (phentolamine, phenoxybenzamine), then beta-blockade | Never beta-block first: unopposed alpha-mediated vasoconstriction causes a hypertensive crisis |
Hypertensive emergency
The IV drugs
labetalol, clevidipine, nicardipine, fenoldopam, nitroprusside.Nitroprusside
a short-acting vasodilator of arteries and veins equally, releasing NO directly to raise cGMP. Its risk is cyanide toxicity.Fenoldopam
a dopamine D1 receptor agonist that dilates the coronary, peripheral, renal and splanchnic beds, lowering blood pressure and promoting natriuresis. Used as a postoperative antihypertensive; can cause hypotension, tachycardia, flushing, headache, and nausea.| Feature | Nitroprusside | Fenoldopam |
|---|---|---|
| Mechanism | Direct NO release, raising cGMP; dilates arteries = veins | Dopamine D1 agonist; coronary, peripheral, renal and splanchnic vasodilation, natriuresis |
| Notes | Short-acting; cyanide toxicity | Postoperative antihypertensive; hypotension, tachycardia, flushing, headache, nausea |
The same thiazide is the right answer for one patient and the trap for the next. Which two comorbidities?
Right in osteoporosis (it retains calcium), wrong in gout (it retains urate). Read the comorbidity, not the blood pressure.
How it's tested
In pheochromocytoma you must give alpha-blockade before beta-blockade, because blocking beta receptors first leaves alpha-mediated vasoconstriction unopposed and precipitates a hypertensive crisis. That ordering question appears repeatedly. Note the recurring theme of the comorbidity table: thiazides help osteoporosis by retaining calcium but trigger gout by retaining urate, so the very same drug is the correct answer in one patient and the trap in another, and you have to read the comorbidity rather than the blood pressure.
Go deeper
First Aid 2026 — CV/Pharmacology (p.321) · B&B — Antihypertensive drugs · Mehlman — HY Cardio (HTN by comorbidity, pheochromocytoma alpha-before-beta)
Flashcards for this page
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Modifiable → (...) inactivity
Modifiable → (...)
Modifiable → (...)
Modifiable → (...)
Modifiable → Excess (...) intake
Modifiable → Excess (...) intake
Nonmodifiable → Increased (...)
Nonmodifiable → (...)
Nonmodifiable → (...)
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