Now, there are a number of other medicines.
I have some medicines that when patients aren’t
controlled with the simpler ones we’ve mentioned.
That is, thiazide diuretics, ACE inhibitors,
angiotensin receptor blockers, calcium blockers.
When the patient still is hypertensive despite
using those drugs or if they couldn’t tolerate
those drugs then I come to some third line
Minoxidil is a very potent vasodilator, it
almost always works. There’s a medicine
called clonidine which works in the central
nervous system to sort of, if you will, turn
down the thermostat of… of blood pressure
control and there are some peripheral drugs
that block the effect of the sympathetic nervous
system on the small blood vessels and thereby
decrease peripheral vascular resistance, so
called alpha blockers. These are all third
First line drugs, thiazides, ACE inhibitors,
angiotensin receptor blocker. Second line
drugs, calcium blockers, Beta Blockers. Third
line drugs, the ones you see here on this
As I mentioned early on in the lecture, it’s
rare to control an individual’s blood pressure
with just one anti-hypertensive drug. It usually
requires two or three. And as I mentioned,
when I was younger and in training, we were
told, “Take one drug and push it to the
maximum dose and then if you'd had... don't control
the blood pressure, start a second drug.”
Well, like so many things in medicine, it
seemed like a good idea at the time, but it
was a bad idea. It markedly increased side
effects and patients often stop their drugs
because of side effects.
In fact, what we have found is much more effective
is to use smaller dose… doses of several
drugs. Two or even three drugs, starting one
drug at a small dose, adding a second drug
at a small dose and a third drug, until we
get control of the blood pressure.
And of course, reducing the dose if we have
side effects and introducing a third or even
sometimes a fourth drug to get good control
over blood pressure with minimal side effects.
So, this step ladder that you see here, this
staircase is really showing you the different
levels for controlling blood pressure. The
drugs that we start with first, the second
line drugs, for… for not good control
with the first line drugs and then to the
higher levels, all the way up.
In other words, you keep increasing the efficacy
of the program by increasing the number of
drugs and slightly increasing the dose. But,
you don’t try and push the maximum dose
right from the very beginning which we used
to do in the old days and it doesn’t work.
Now, you can see here, what we’ve listed
here are a number of the double-blind randomized
controlled trials. As you know, they're all
listed by acronyms that is just the initials
there on left hand side of the slide. These
are large randomized controlled trials with
thousands of patients and what the colored
bar show you, is how many drugs on average
it took to control the blood pressure in these
various trials. And you can see, the top trial,
it took two and a half drugs to control, on
average, to control blood pressure, but in
the later trials down below, it took three
or four drugs.
So, that... I said that from the very beginning,
one drug usually doesn’t control blood pressure.
It usually requires two or three. We start
with lower doses of each of the drugs and…
and we almost always get good control of blood
pressure. I see a number of patients all the
time who are referred to me by primary care
doctors because their primary care doctors
said, “It’s impossible to control your
blood pressure.” I have never seen a patient
that I couldn’t control their blood pressure
by manipulating the drugs appropriately. So…
but, it takes some work with a patient that’s
Fortunately, most patients are not challenging.
Couple of drugs at modest doses and the patients
do beautifully and their blood pressure’s
120, 130 over 70 to 80.
Well, that brings us to the end of lecture
14 and the end of the series, “Introduction
to Cardiology”. I hope you’ve learned
a lot. If you still have questions, you can
find my e-mail address at the end of all the
editorials that I write for the American Journal
of Medicine. That’s the journal that I’m
the Editor-In-Chief of and I’ll be happy
to answer your questions by e-mail.
Thanks very much for participating in this