The choice of an initial antihypertensive agent.

With the current availability of a plethora not only of blood pressure-lowering medications but also of classes thereof and the concern that the long-term use of some of these may result in adverse effects which may offset their benefits has come the recognition of the importance of the choice of an initial antihypertensive agent. Indeed, the initially chosen medication will often be taken for the longest time. The purpose of this review is to consider nine of the major factors permitting a rational choice of medication: antihypertensive efficacy, mechanism of action, safety, patient acceptance (quality of life), cost, numbers of doses per day, need for laboratory follow-up, potential interactions with other drugs, and additional salutary effects. The question of the role of nondiuretic monotherapy is, of necessity, an integral component of this discussion. Preliminary data indicate that the use of this approach with some of the newer agents, including converting enzyme inhibitors and calcium channel blockers, constitutes excellent therapy, at least in certain patients. Finally, because one of the new approaches to antihypertensive therapy is comprehensive risk management, the effect of medication on the lipid profile is considered in some detail.