I have the recollection that alpha blockers are not recommended first line because of adverse CCD outcomes (was it ALLHAT?) but, really, should I be using them at all in primary care for hypertension?Had 74 yo gentlemen today on terazosin and ramipril for BP. Recent ER visit for hypotension recorded at home 90-110 systolic. In ER and here BP 120-130 systolic. ECG in ER: bigemeny. Holster in May short run asymptomatic VT. Normal ECHO in May, EF 55-60%. I’m suspicious that recent episode may have been symptomatic VT (Ix and referral underway) but is terazosin doing more harm than good?
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- Answered 6 Sep 2019 Conflict of interest declaration: None Hypertension Canada have a 2018 guideline “Choice of therapy for adults with hypertension without compelling indications for specific agents” . The first section of which discusses initial choices of intervention which I recommend you read via the link below. Further down in the guideline it specifically mentions alpha-blockers: "Alpha-blockers were inferior to diuretics in the ALLHAT trial and this resulted in early termination of the alpha-blocker arm of ALLHAT. Alpha-blockers can be considered if add-on therapy is necessary in resistant hypertension but are not indicated as a first line drug class." You may also be interested in the Cochrane SR (2018) on first-line treatments for hypertension  and they report: "There were no RCTs comparing first‐line use of angiotensin receptor blockers or alpha blockers." References 1) https://guidelines.hypertension.ca/prevention-treatment/uncomplicated-hypertension-therapy/ 2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513559/
- Answered 6 Sep 2019 Conflict of interest declaration: None I've just spotted that the UK's NICE published an update to their guideline "Hypertension in adults: diagnosis and management" around a week ago . They mention alpha-blockers twice: "1.4.49 Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/l. " and "The committee agreed that the recommendation for considering alpha- or beta-blockers should be retained based on significant clinical experience of their safe and effective use and because adding a further drug is likely to have a greater effect on blood pressure than increasing the thiazide diuretic dose." Best read the guideline to understand the context! Reference 1) https://www.nice.org.uk/guidance/ng136/resources/hypertension-in-adults-diagnosis-and-management-pdf-66141722710213