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By setting the History to On, you will always have a drop-down list of the values you last used in a selection field, according to the Expiration, Maximum Permitted File Size, and Maximum Number of Entries that you set, as shown in Figure 1-12 Expert Data Controls Click the Customizing Local Layout icon (shown earlier), then select Options, and select the Expert tab Options selected in matchcodes are generally created by a key index This key is not normally available for the user to see Consequently, people sometimes configure the description of the values that may be selected to describe the key of the object There is no need to include the key in the description if the users have the Show Keys in All Drop Down Lists checkbox marked as active Sort Items by Key ensures the user is presented with a logical list to select from

These agents are now used infrequently and usually in refractory hypertension Reserpine remains a cost-effective antihypertensive agent (Table 11 10) Its reputation for inducing mental depression and its other side effects sedation, nasal stuffiness, sleep disturbances, and peptic ulcers has made it unpopular, though these problems are uncommon at low dosages Guanethidine and guanadrel inhibit catecholamine release from peripheral neurons but frequently cause orthostatic hypotension (especially in the morning or after exercise), diarrhea, and fluid retention

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Prazosin, terazosin, and doxazosin (Table 11 10) block postsynaptic -receptors, relax smooth muscle, and reduce blood pressure by lowering peripheral vascular resistance These agents are effective as single-drug therapy in some individuals, but tachyphylaxis may appear during longterm therapy and side effects are relatively common These include marked hypotension and syncope after the first dose which, therefore, should be small and given at bedtime Post-dosing palpitations, headache, and nervousness may continue to occur during long-term therapy; these symptoms may be less frequent or severe with doxazosin because of its more gradual onset of action Unlike the -blockers and diuretics, the -blockers have no adverse effect on serum lipid levels in fact, they increase HDL cholesterol while reducing total cholesterol Whether this is beneficial in the long term has not been established In ALLHAT, persons receiving doxazosin as initial therapy had a significant increase in heart failure hospitalizations and a higher incidence of stroke relative to the persons receiving diuretics, prompting discontinuation of this arm of the study To summarize, -blockers should generally not be used as initial agents to treat hypertension except perhaps in men with symptomatic prostatism

Historically, data from a number of large trials support the overall conclusion that antihypertensive therapy with diuretics and -blockers has a major beneficial effect on a broad spectrum of cardiovascular outcomes, reducing the incidence of stroke by 30 50% and of congestive heart failure by 40 50%, and halting progression to accelerated hypertension syndromes The decreases in fatal and nonfatal coronary heart disease and cardiovascular and total mortality have been less dramatic, ranging from 10% to 15% Similar placebo-controlled data pertaining to the newer agents are generally lacking, except for stroke reduction with the calcium channel blocker nitrendipine in the Systolic Hypertension in Europe trial However, there is substantial evidence that ACE inhibitors, and to a lesser extent ARBs, reduce adverse cardiovascular outcomes in other related populations (eg, patients with diabetic nephropathy, heart failure, or postmyocardial infarction and individuals at high risk for cardiovascular events) Most large clinical trials that have compared outcomes in relatively unselected patients have failed to show a difference between newer agents such as ACE inhibitors, calcium channel blockers, and ARBs and the older diuretics and -blockers with regard to survival, myocardial infarction, and stroke Where differences have been observed, they have mostly been attribut-

Methyldopa, clonidine, guanabenz, and guanfacine (Table 11 10) lower blood pressure by stimulating -adrenergic receptors in the central nervous system, thus reducing efferent peripheral sympathetic outflow These agents are effective as single therapy in some patients, but they are usually used as second- or third-line agents because of the high frequency of drug intolerance, including sedation, fatigue, dry mouth, postural hypotension, and impotence An

Cost of 30 Days Treatment (Average Dosage)1

Comments May HDL and LDL cholesterol May provide short-term relief of obstructive prostatic symptoms Less effective in preventing cardiovascular events than diuretics

-Adrenoceptor blockers Prazosin Terazosin Minipress Hytrin 1 mg hs 1 mg hs 2 20 mg in 2 or 3 doses 1 20 mg in 1 or 2 doses 1 16 mg daily $078/5 mg $160/1, 2, 5, 10 mg $097/4 mg $4680 (5 mg twice daily) $4800 (5 mg daily) $2910 (4 mg daily) Syncope with first dose; postural hypotension, dizziness, palpitations, headache, weakness, drowsiness, sexual dysfunction, anticholinergic effects, urinary incontinence; first-dose effects may be less with doxazosin

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