Hypertension in Adults

Hypertension is a persistent elevation in blood pressure that increases cardiovascular, cerebrovascular, and kidney risk. Current Canadian guidance defines hypertension in adults as blood pressure at or above 130/80 mm Hg when measured using recommended methods.^[1]

Most patients have no reliable symptoms, so diagnosis depends on accurate measurement rather than how the patient feels. Markedly elevated readings with acute neurologic, cardiac, respiratory, or visual symptoms require urgent medical assessment.^[2]

Reduce preventable cardiovascular and kidney events while avoiding treatment-related harm. A systolic blood pressure below 130 mm Hg is the usual treatment target when it is tolerated; individualize when frailty, orthostasis, or limited life expectancy changes the balance.^[1]

• Older age, family history, tobacco exposure, excess sodium, low physical activity, and excess alcohol.
• Diabetes, chronic kidney disease, dyslipidemia, obesity, established cardiovascular disease, and sleep apnea.
• Medicines and substances that can raise blood pressure, including NSAIDs, stimulants, decongestants, systemic corticosteroids, and excess licorice.

Confirm technique, cuff size, repeated readings, and the possibility of white-coat or masked hypertension. Use validated automated office measurement and confirm with out-of-office measurement when feasible.^[3]

• Review adherence, current medicines, pregnancy possibility, alcohol, sodium, and symptoms of secondary causes.
• Assess global cardiovascular risk and target-organ effects; obtain patient-specific laboratory testing according to the clinical context.

• Use a dietary pattern rich in vegetables, fruit, whole grains, and minimally processed foods; reduce sodium.
• Build regular aerobic and resistance activity within the patient's capacity.
• Support weight management, tobacco cessation, moderation of alcohol, and adequate sleep.

Lifestyle measures are recommended for all patients and continue after drug therapy starts.^[1]

Start pharmacotherapy at 140/90 mm Hg or higher, and consider it at systolic 130–139 mm Hg when cardiovascular risk is high. Initial choices commonly include a thiazide or thiazide-like diuretic, a long-acting dihydropyridine calcium-channel blocker, an ACE inhibitor, or an angiotensin receptor blocker. Combination treatment is often appropriate when blood pressure is well above target.^[1]

Pregnancy and breast feeding require a separate benefit-risk review because usual adult targets and drug choices do not automatically apply. Confirm pregnancy status when relevant and obtain pregnancy-specific prescriber guidance before initiating, continuing, or changing therapy.^[2]

• Reassess blood pressure, adherence, orthostatic symptoms, and adverse effects after initiation or dose changes.
• Monitor renal function and electrolytes when the selected drug or patient factors warrant it.
• Once stable, continue periodic office or home readings and revisit cardiovascular risk.

• Ask the patient to bring the home monitor and readings; confirm technique.
• Simplify the regimen and use single-pill combinations when clinically appropriate.
• Before labeling resistant hypertension, check measurement, adherence, substances that raise blood pressure, and secondary causes.

1. Validate the measurement and identify any hypertensive emergency features.
2. Confirm persistent hypertension with repeat or out-of-office readings.
3. Assess cardiovascular risk, target-organ effects, comorbidities, pregnancy, and contributors.
4. Start lifestyle treatment for everyone; add pharmacotherapy according to pressure and risk.
5. Select a class using comorbidities, contraindications, interactions, laboratory values, cost, and patient preference.
6. Titrate, combine complementary classes when needed, and monitor until the individualized target is reached.

How to use these tables: Doses are adult oral hypertension doses and require patient-specific confirmation. Select any drug name to open its complete Pharmasist Drug Database page.

Current Canadian guidance favours initial low-dose combination treatment using two complementary first-line classes: an ACE inhibitor or ARB, a thiazide or thiazide-like diuretic, and/or a long-acting dihydropyridine calcium-channel blocker. If two drugs do not achieve target, use all three classes; do not combine an ACE inhibitor with an ARB. Spironolactone is the preferred next consideration for confirmed resistant hypertension when potassium and kidney function allow.^{[2][4][5][6][7]}

Alpha1-adrenergic antagonists

Not initial hypertension therapy. Orthostatic hypotension, headache, drowsiness, palpitations and nasal congestion are common class concerns. First-dose or rapid-titration syncope can occur; start low, titrate slowly and restart at the initial dose after a multi-day interruption. Additive hypotension may occur with other blood-pressure-lowering drugs.

Angiotensin-converting enzyme inhibitors

Avoid in pregnancy and counsel people who could become pregnant. Dry cough, hyperkalemia and uncommon angioedema are class effects. Renal failure can occur with bilateral renovascular disease, volume depletion or concurrent NSAID use. Potassium supplements and potassium-sparing drugs increase potassium; NSAIDs can blunt effect and increase renal risk; lithium concentrations may rise. Consider a 50% lower start in diuretic-treated or hypovolemic patients and reassess serum creatinine and potassium after initiation and titration.

Angiotensin II receptor blockers

Avoid in pregnancy and counsel people who could become pregnant. Hyperkalemia and renal dysfunction can occur, particularly with bilateral renovascular disease, hypovolemia or NSAID exposure; angioedema has been reported. Potassium-retaining drugs raise potassium, NSAIDs reduce antihypertensive effect and increase renal risk, and lithium concentrations may increase. Start lower when volume depleted and recheck serum creatinine and potassium.

Beta-adrenergic antagonists - nonselective

Not first-line solely for uncomplicated hypertension; retain for a compelling indication such as angina, post-myocardial infarction, selected heart failure or rate/rhythm control. Fatigue, bradycardia, reduced exercise capacity, headache, sexual dysfunction, sleep effects, depression, heart failure and heart block may occur. Avoid in asthma, severe peripheral arterial disease and unpaced second- or third-degree block. Digoxin, non-dihydropyridine calcium-channel blockers and amiodarone add bradycardia or cardiac depression. Never stop abruptly; taper to avoid rebound hypertension and ischemia.<cite data-reference-id="9e03152a-78c4-47ea-c742-87a706baf525"></cite>

Beta1-selective adrenergic antagonists

Cardioselectivity can reduce, but does not eliminate, noncardiac beta-blocker effects. Use for a compelling indication rather than initial uncomplicated hypertension. Apply the same heart-block, asthma, peripheral arterial disease and gradual-withdrawal precautions as other beta-blockers.

Beta-adrenergic antagonists with intrinsic sympathomimetic activity

Agents with intrinsic sympathomimetic activity have less effect on resting heart rate, but retain class precautions and are not preferred first-line antihypertensives.

Beta-adrenergic antagonist with alpha1-blocking activity

Labetalol combines beta blockade with alpha1 blockade. In addition to beta-blocker risks, edema, dizziness, nasal congestion and postural hypotension may occur.

Calcium-channel blockers - dihydropyridine

Long-acting dihydropyridines are complementary first-line options. Ankle edema, flushing, headache and palpitations are common. These agents are CYP3A4 substrates; azole antifungals, protease inhibitors, macrolides, quinidine and grapefruit can raise concentrations.

Calcium-channel blockers - nondihydropyridine

Diltiazem and verapamil slow heart rate and atrioventricular conduction. Headache, dizziness, bradycardia, heart block and new or worsening heart failure can occur. Avoid or use cautiously in heart failure or unpaced second- or third-degree block. Both are CYP3A4 substrates and inhibitors and can interact with beta-blockers, digoxin, amiodarone, carbamazepine, cyclosporine and some statins.

Centrally acting antihypertensive agents

Not routine first-line therapy. Sedation, dry mouth, orthostatic hypotension and dizziness are common. Abrupt clonidine withdrawal can produce severe rebound hypertension; methyldopa requires attention to depression, liver, blood and fluid-retention adverse effects.

Potassium-sparing diuretics

Not initial monotherapy. Hyperkalemia risk rises with kidney impairment, potassium supplements, ACE inhibitors, ARBs, aliskiren and NSAIDs. Monitor serum creatinine and potassium.

Thiazide and thiazide-like diuretics

First-line complementary options. Hypotension, weakness, cramps, sexual dysfunction, hypokalemia, hyponatremia, hyperuricemia, dysglycemia and lipid changes can occur; uncommon effects include azotemia, blood dyscrasias, sulfonamide-type reactions, fatigue and photosensitivity. Lithium excretion falls, NSAIDs reduce pressure response, hypokalemia increases digoxin toxicity, and glucose-lowering drug response may be reduced. Monitor serum creatinine, sodium and potassium; consider gout, diabetes and arrhythmia risk. Standard thiazides become less effective at low kidney function.<cite data-reference-id="af14263b-89d5-48fb-d853-98b817cb0636"></cite>

ACE inhibitor/calcium-channel blocker combination

Fixed-dose products retain all component contraindications, adverse effects, interactions and monitoring. Avoid ACE-inhibitor combinations in pregnancy.

ACE inhibitor/diuretic combinations

Fixed-dose products combine ACE-inhibitor and thiazide/thiazide-like effects. Avoid in pregnancy. Monitor kidney function, sodium and potassium; review potassium products, NSAIDs, lithium, gout, diabetes and volume status.

ARB/diuretic combinations

Fixed-dose products combine ARB and thiazide/thiazide-like effects. Avoid in pregnancy. Monitor kidney function, sodium and potassium; review potassium products, NSAIDs, lithium, gout, diabetes and volume status.

Beta-blocker/diuretic combinations

These fixed-dose products combine beta-blocker and thiazide/thiazide-like adverse effects and interactions. They are not preferred initial therapy for uncomplicated hypertension; avoid abrupt beta-blocker withdrawal and monitor kidney function and electrolytes.

Calcium-channel blocker/ARB combination

This complementary fixed-dose pairing retains ARB pregnancy, kidney and potassium precautions plus dihydropyridine edema and CYP3A4 considerations.

Calcium-channel blocker/HMG-CoA reductase inhibitor combination

This product treats blood pressure and a lipid indication in one tablet; select each component dose independently and retain all amlodipine and atorvastatin precautions.

Diuretic combinations

These products pair hydrochlorothiazide with a potassium-sparing diuretic. They can reduce thiazide-associated potassium loss but can cause hyperkalemia, especially with kidney impairment or other potassium-raising therapy. Continue sodium, potassium and kidney-function monitoring.

Evidence note: The drug inventory, doses, adverse effects, interactions and product groupings were independently rewritten from the supplied Canadian pharmacist table. Guideline positioning and sequencing follow the 2025 Hypertension Canada guideline and its cited evidence.^{[8][2][4][5][9][10][6][7]}