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Alpha-blockers in Treatment Algorithm — EECC MCQ

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ModerateHypertension & Preventive CardiologyAlpha-blockers in Treatment AlgorithmEECC

A 60-year-old man with hypertension is started on doxazosin for resistant hypertension as fourth-line agent. He develops postural dizziness. How do alpha-blockers fit in the hypertension treatment algorithm?

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Correct answer: A — Alpha-blockers (doxazosin) are positioned as fourth-line agents in the 2024 ESC Hypertension Guidelines for resistant hypertension, AFTER maximising the triple combination of ACEi/ARB + CCB + thiazide and adding spironolactone as fourth agent — doxazosin is fifth-line or an alternative when spironolactone is contraindicated

The 2024 ESC Hypertension Guidelines treatment algorithm: Step 1: dual SPC (ACEi/ARB + CCB or thiazide); Step 2: triple SPC (ACEi/ARB + CCB + thiazide); Step 3 (resistant HTN): add spironolactone 25-50 mg (PATHWAY-2 trial showed spironolactone is the most effective fourth agent); Step 4: if BP remains uncontrolled despite triple + spironolactone, add alpha-blocker (doxazosin) OR beta-blocker OR further diuretic (amiloride). Alpha-blockers block postsynaptic alpha-1 receptors causing vasodilation. Postural hypotension is the main side effect (particularly first-dose). Doxazosin is also used for concurrent BPH symptoms. The ALLHAT trial showed doxazosin monotherapy was inferior to chlorthalidone for preventing HF events, but as an add-on agent it remains valuable.

Reference: ESC (2024): Hypertension Guidelines; PATHWAY-2 Trial