Dr Michael Parkinson · Clinical tools

Antihypertensive considerations

Select the relevant clinical features. Compare reasons to favour each drug class with reasons to avoid it or use extra care.

Adult clinician decision support · Evidence checked 11 October 2026 · Draft for clinical review

How to read this: All potential reasons are listed in light grey. Ticking a feature highlights its relevant reasons: green for a potential benefit, yellow for caution, monitoring or review, and red for a reason against use or an avoidance/review flag. Read the accompanying restrictions and evidence. Grey means not selected, not absent. The number of highlighted items is not a treatment score.

Class comparison

Reasons for and against

Every potential reason stays in view; selected reasons stand out. Benefits and concerns may coexist.

Favours useCaution / reviewReason against / review

On a small screen, scroll the table sideways to read all three columns.

All potential reasons in favour and against antihypertensive drug classes. Unselected reasons are grey; selected reasons are highlighted.
Drug class	Reasons in favour	Reasons against / cautions

Scope: This is a class-level considerations aid, not a prescription, dose calculator or validated ranking. Confirm the indication, BP, pulse, orthostatic symptoms, current medicines, renal function, electrolytes and each medicine's Australian product information. It does not check every interaction or contraindication. Patients should not start, stop or change treatment using this page.

HFrEF means heart failure with reduced ejection fraction. CCB means calcium-channel blocker. MRA means mineralocorticoid receptor antagonist. ACE inhibitor, ARB and ARNI are different options; their indications and switching rules matter. SGLT2 inhibitors and finerenone may be important HF/CKD treatments, but are outside this conventional BP-drug comparison.

Privacy: This component has no patient identifiers, analytics, network requests or saved selections. Refreshing or clearing the page resets it. The surrounding Squarespace site may have its own analytics.

Clinical notes & evidence

Low eGFR alone does not automatically exclude an ACE inhibitor or ARB. KDIGO supports continuing them below eGFR 30 if tolerated; albuminuria strengthens the indication. Check creatinine and potassium after starting or changing treatment, usually within 2–4 weeks and sooner when risk is high. A creatinine rise over 30% needs evaluation.
Hyponatraemia remains a particular diuretic concern and also gives ACE inhibitors, ARBs and ARNIs a yellow review/monitoring flag. Assess the cause and volume status and monitor Na, K, renal function and BP. A low serum sodium does not itself establish salt/volume depletion or a class contraindication. Hyperkalaemia raises a RAAS-blocker/MRA concern; manageable hyperkalaemia does not automatically require stopping an ACE inhibitor or ARB.
Moxonidine's bradycardia and high-grade AV-block flags are displayed yellow for review. Their text retains the Australian PI contraindications: HR below 50, severe bradyarrhythmia including sick sinus syndrome, and second- or third-degree AV block.
For HFrEF, the evidence-based beta blockers include bisoprolol, carvedilol and metoprolol succinate. Verapamil and diltiazem should be avoided in HFrEF; amlodipine does not share that prohibition. ACE inhibitor/ARB benefit applies when ARNI is unsuitable.
Active fluid overload/congestion highlights a reason against starting either CCB family. Treat congestion and reassess LV function first. For DHP CCBs this is a clinical preference against initiation, not an absolute contraindication to amlodipine in stable HF.
For HFrEF, routine steroidal MRA initiation requires eGFR above 30 mL/min/1.73 m² and potassium below 5.0 mmol/L, with close monitoring. Resistant-hypertension protocols may use stricter potassium eligibility. Combining an MRA with an ACE inhibitor, ARB or ARNI can be appropriate under monitoring.
Pregnancy needs a dedicated obstetric pathway. Labetalol, long-acting nifedipine and methyldopa are specific options, not endorsements of every agent in their class. Planning pregnancy requires medication review before conception.
Long-acting nitrates are an angina adjunct, not routine hypertension treatment. Nitrates combined with hydralazine have a specific HFrEF role; nitrates alone do not replace disease-modifying HF therapy.
“Resistant hypertension” means BP remains uncontrolled after adherence, measurement and secondary causes are assessed, despite an appropriate tolerated regimen including a diuretic.

Dr Michael Parkinson Cardiologist

Links