Aztel Trio


  • Persistently elevated Blood Pressure
  • Uncontrolled hypertension is a risk factor for:
    • MI
    • Stroke
    • CRF ( Chronic Renal Failure)
    • Blindness
  • “ Silent Killer “- Leading cause of death

2017 AHA/ACC : Categories of BP in Adults*

BP Category SBP   DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm Hg and <80 mm Hg
Stage 1 130–139 mm Hg or 80–89 mm Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.

BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions

Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg
Clinical CVD or 10-year ASCVD risk ≥ 10% ≥ 130/80 <130/80
No clinical CVD and 10-year ASCVD risk <10% ≥ 140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults) ≥ 130 (SBP) <130 (SBP)
Specific comorbidities
Diabetes mellitus ≥ 130/80 <130/80
Chronic kidney disease ≥ 130/80 <130/80
Chronic kidney disease after renal transplantation ≥ 130/80 <130/80
Heart failure ≥ 130/80 <130/80
Stable ischemic heart disease ≥ 130/80 <130/80
Secondary stroke prevention ≥ 140/90 <130/80
Secondary stroke prevention (lacunar) ≥ 130/80 <130/80
Peripheral arterial disease ≥ 130/80 <130/80

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

Canadian Hypertension guidelines 2017

What’s new?

  • Longer acting (thiazide-like- Chlorthalidone) diuretics are preferred vs. shorter acting (Hydrochlorothiazide)
  • Single pill combinations should be used as a first line treatment (regardless of the extent of BP elevation)

Anti-hypertensive Drugs

All agents are first-line and equally effective, some offer additional benefits in co-morbid conditions…

Telmisartan: Bifunctional ARB

Selectively blocks AT1 receptor + Activates PPAR Gamma receptor

  • Highly selective AT1 receptor blocker
  • High affinity for AT1 receptors
  • Prevents binding of Angiotensin II with AT1 receptors

    Blocks actions of angiotensin II

    Lowers PVR and preload- lowering of BP

Telmisartan: Unique ARB

  • Only ARB which is approved for primary prevention of MI and stroke.
  • Longest half life (>24 hrs) of all ARBs; better patient compliance with single daily dose.
  • Better 24-hour BP control.
  • Acts as a selective modulator of Peroxisome proliferator-activated receptor gamma (PPAR-γ), a central regulator of insulin and glucose metabolism- improves control of diabetes and lowers serum lipids ( LDL-C,TG)
  • Telmisartan also appears to improve renal function
  • No need to adjust dose in renal impairment

Amlodipine: Actions

  • Long – acting calcium channel blocker
  • Dilates peripheral arterioles and lowers peripheral vascular resistance
  • Once daily dose, controls BP for 24 hours
  • No adverse effect on glucose metabolism- safe in diabetics
  • No adverse effect on serum lipid levels or sexual functions
  • Very well tolerated
  • Additive anti-hypertensive action, when combined with Diuretics/Beta blockers/ACEI/ARB

Chlorthalidone Vs Hydrochlorothiazide

  • Long acting Thiazide-like Diuretic-Acts on kidneys- increases urine output and sodium excretion- lowers blood volume
  • Longer half life-longer duration of action:
    • 40-72 hr (vs. 6-15 hr for hydrochlorothiazide)
  • Better 24 hr BP control
  • More potent (~2x)
    • 12.5 mg chlorthalidone is equivalent to 25 mg hydrochlrothiazide
  • Blood glucose lowering effect-beneficial in diabetics
  • Lowers LDL-C, TC- Preferred in patients with dyslipidemia

Aztel Trio: Indications

  • 40-72 hr (vs. 6-15 hr for hydrochlorothiazide)
  • Hypertension (SBP > 160/DBP > 100)
  • Not controlled with Telmisartan dual therapy
  • Hypertensies with High C Risk
  • (existing CAD, multiple C risk Factors or Diabetes or CKD)
  • Diabetic  hypertensies
  • Hypertensie with chronic kidney disease
Starting dose One Tablet Daily
Dose titration after 4-6 weeks Two Tablets Daily
Recommended time of administration Preferably in Morning
Mild to moderate Renal dysfunction No need for dose adjustment
Liver impairment Use with caution