Choosing the right antihypertensive drug to avoid intradialytic hypotension.

Intradialytic hypotension (IDH) is a significant complication in haemodialysis (HD) patients, affecting cardiovascular stability and treatment outcomes. Antihypertensive medications, while crucial for blood pressure control, can exacerbate IDH, necessitating careful drug selection and management. This review highlights the differential effects at the HD population level of drug classes such as beta and alpha-beta blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II antagonists, diuretics and calcium antagonists. Beta and alpha-beta blockers are linked to a higher risk of IDH due to their impact on heart rate and myocardial contractility, which can impair cardiovascular reflexes during dialysis. ACEIs and angiotensin II antagonists may increase the risk of hypotension by reducing vascular resistance. Diuretics can worsen volume depletion, especially when combined with ultrafiltration. Conversely, calcium antagonists have been associated with a lower risk of IDH in low-power clinical studies. Target trials represent an opportunity to generate high-quality evidence in the absence of randomized controlled trial (RCT) data. To fill the knowledge gap, this review discusses a target trial emulation study by Zoccali et al. that provides insights into the comparative risks of antihypertensive drugs using observational data. This study underscores the need for individualized treatment plans and highlights the importance of further research, particularly RCTs, to validate findings and explore long-term cardiovascular outcomes. This review aims to guide clinicians in optimizing antihypertensive therapy for HD patients, balancing effective blood pressure control with minimizing IDH risk.