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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e151 Class Drug Usual Dose, Range (mg/d)∗ Daily Frequency Comments Diuretics—potassiumsparing Amiloride 5-10 1 or 2 As monotherapy, these agents are minimally effective antihypertensive agents. Combination therapy of a potassium-sparing diuretic with a thiazide-type diuretic can be considered in patients with hypokalemia on thiazide-type diuretic monotherapy. Avoid use in patients with significant CKD (eg, GFR <45 mL/min). Triamterene 50-100 1 or 2 Diuretics—aldosterone antagonists Eplerenone 50-100 1 or 2 These are preferred agents in primary aldosteronism and resistant hypertension. Spironolactone is associated with greater risk of gyneco mastia and impotence compared with eplerenone. Demonstrated efficacy as fourth-agent add-on therapy for resistant hypertension. Avoid use with K+ supplements, other K+-sparing diuretics, or significant renal dysfunction (eg, GFR <45 mL/min). Eplerenone often requires twice-daily dosing for ad equate BP lowering. Avoid use in pregnancy. Spironolactone 25-100 1 Beta blockers— cardioselective Atenolol 25-100 2 Beta blockers are not recommended as first-line agents unless the patient has CHD or HF. These are preferred in patients with bronchospastic air way disease requiring a beta blocker. Bisoprolol and metoprolol succinate are preferred in pa tients with HFrEF. Avoid abrupt cessation. Betaxolol 5-20 1 Bisoprolol 2.5-10 1 Metoprolol tartrate 100-200 2 Metoprolol succinate 50-200 1 Beta blockers—cardioselective and vasodilatory Nebivolol 5-40 1 Nebivolol induces nitric oxide-induced vasodilation. Avoid abrupt cessation. Beta blockers— noncardioselective Nadolol 40-120 1 Avoid use in patients with reactive airways disease. Avoid abrupt cessation. Propranolol IR 80-160 2 Propranolol LA 80-160 1 Beta blockers—intrinsic sympathomimetic activity Acebutolol 200-800 2 Generally avoid, especially in patients with CHD or HF. Avoid abrupt cessation. Penbutolol 10-40 1 Pindolol 10-60 2 Combined alpha and beta blockers Carvedilol 12.5-50 2 Use of carvedilol is preferred in patients with HFrEF. Avoid abrupt cessation. Carvedilol phosphate 20-80 1 Labetalol 200-1200 2 Direct renin inhibitor Aliskiren 150-300 1 Do not use in combination with ACEi or ARB. Aliskiren is very long acting. There is an increased risk of hyperkalemia in CKD or in those on K+ supplements or K+-sparing drugs. Aliskiren may cause acute renal failure in patients with severe bilateral renal artery stenosis. Avoid use in pregnancy. Alpha-1 blockers Doxazosin 1-16 1 These are associated with orthostatic hypotension, es pecially in older adults with a greater BP drop with first dose effect. These may be considered a second-line agent in patients with symptomatic benign prostatic hypertrophy. Prazosin 2-20 2 or 3 Terazosin 1-20 1 or 2 Table 13. Continued (Continued ) Downloaded from http://ahajournals.org by on October 7, 2026