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''NICE guidelines - 2012''
CCB better than thiazides
bendroflumethazide not thiazide of choice

ABCD algorithm - (Ace BB Ca channel Diuretic)

Step 1 <55 - ACE or ARB (don't combine as no added benefit and inc SE)
step 1 >55 / blacks - CCB

step 2 - CCB + ACE/ARB

step 3 - Add diuretic - esp if in failure (not bendroflumethazide but Indapamide SR (1.5-2.5), or chlorthalidone (12.5 or 25mg)) 

step 4 (resistent HT) ?under specialist advice? or consider ...
if K>4.5 double dose diuretic
if K<4.5 - Spironolactone 25mg od
??alpha blocker (doxasocin) or BB or other new

BB - reduce stroke and heart disease but not as well as other drugs, if using BB for other things - migraine, anxiety or used already - then use

?ARB better tolerated than ACE and longer action

''Resistant HT ''
already on ACD (optimal or best tolerated dose) and still not controlled (>140/90 in clinic) 
1/2 million people in UK
remember lifestyle advice (smoking weight exercise) and compliance
if acute volume depletion (eg vomiting, diarrhoea, dehydrated) can get rapid drop in BP with  acute renal impairment / acute hypotension (already lots of treatment so no reserve)
usually resistant HT retains Na - so different diuretic which blocks a different part of renal tubule
often consider referral but may try ....

''spironolactone ''
may work dramatically
may raise potassium (so beware in renal impairment esp with diabetes, or if K already up) - so must monitour K - check at base and only give if below 4.5,  check U/E within 2-3/52 and once stable, annual check (Na can slowly drop)
can cause gynaecomastia / nipple tenderness - have to stop
if really dramatic remember Conn's adenoma

''Blacks''
CCB (or D) at any age as HT is more related to Na problems (low renin HT so ACE less good)
often HT is resistent and needs 2nd drug - better to use ARB as ACE causes inc incidence of angioedema 

''Direct Renin Inhibitors'' (Aliskiren)
inhibits renin so blocks angiotensinogen to angiotensin
trials looked at BP fall (sim to ACE) but not yet at mortality
SE uncommon ? diarrhoea
role ? in pts intolerant of older drugs