Antihypertensives, Heart Failure and Angina Drugs for NEET PG Pharmacology: ICMR 2026 Protocols, ACE Inhibitors, ARNI, Nitrates

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🎯 Exam priority: High. Cardiovascular drugs are the biggest block in Pharmacology. Expect: first-line choice for a new hypertensive, a cough on enalapril, a pregnant woman on an ARB, a man on sildenafil with chest pain, and the heart-failure drug that saves lives.

CBME mapping: PH 4.1–4.5. Protocols follow India's ICMR Standard Treatment Workflows (2026).

Hypertension: Diagnosis and Targets (ICMR 2026)

• Diagnosis: ≥ 140/90 on two different visits; a single visit is enough if ≥ 160/100.

• Targets: < 140/90 for all adults; < 130/80 with diabetes, CKD or established CVD if tolerated; < 150/90 at age ≥ 80.

• Lifestyle: salt < 5 g a day, no tobacco or alcohol, 30 minutes of activity daily, BMI < 23.

Hypertension: Drug Choice

• Two drugs from two classes can be the default first step for most adults, preferably as a single pill. Monotherapy only for low-risk grade 1, age ≥ 80 or frailty.

• Pair a CCB or thiazide-like diuretic with a RAAS blocker (ACE inhibitor or ARB). Never combine two RAAS blockers (kidney injury).

• Beta-blockers are for hypertension with angina, after MI or with heart failure.

ICMR hypertension step-up protocol 1: amlodipine 5 mg, add telmisartan 40 mg, raise telmisartan to 80 mg, raise amlodipine to 10 mg, add chlorthalidone 12.5 mg, then consider spironolactone, each step after 4 weeks. Drawn by TrackNation.

Hypertensive urgency (≥ 180/120 without acute organ damage): start oral drugs, lower BP gradually over 24–48 hours, no IV drugs; review within a week. With red-flag symptoms, stabilise and refer.

Other Antihypertensives: Label Warnings

• Hydralazine: a lupus-like syndrome (including glomerulonephritis).

• Methyldopa: positive Coombs test, haemolytic anaemia, liver disorders.

• Sodium nitroprusside: releases cyanide; never run at the maximum rate for more than 10 minutes.

• Verapamil: avoid in 2nd/3rd-degree AV block; with beta-blockers ventricular function can deteriorate.

• Furosemide: ototoxicity (tinnitus, deafness), especially with rapid injection, renal failure, high doses or aminoglycosides.

Heart Failure (ICMR 2026)

• Decongest first with IV furosemide (and oxygen if saturation < 90%).

• Then start an ARNI (sacubitril-valsartan) and spironolactone; add a beta-blocker after decongestion (carvedilol 3.125–25 mg twice daily, metoprolol or bisoprolol, started low and uptitrated every 1–2 weeks); add an SGLT2 inhibitor (dapagliflozin reduces CV death and heart-failure hospitalisation). Consider ivabradine, vericiguat and digoxin at tertiary level.

• HFrEF = ejection fraction < 35% (ICMR). Give pneumococcal and influenza vaccines.

• ARNI: allow a 36-hour washout when switching from or to an ACE inhibitor (angioedema risk).

• Spironolactone: hyperkalaemia (watch potassium and creatinine), gynaecomastia. Ivabradine: blocks the HCN channel (the pacemaker I_f current) and slows the heart.

Stable Angina (ICMR 2026)

• Stable angina: effort-related pain relieved by rest or nitroglycerin within 1–2 minutes.

• Control symptoms: metoprolol with or without a dihydropyridine CCB; add nitrates if needed; then trimetazidine, nicorandil or ranolazine.

• Prevent events: aspirin 75 mg (clopidogrel 75 mg if aspirin is not tolerated) and high-intensity statins (atorvastatin 40–80 mg or rosuvastatin 20–40 mg); ACE inhibitor. Prefer CABG over PCI in diabetes with multivessel or left-main disease.

• Sublingual nitroglycerin: one tablet every 5 minutes, no more than three in 15 minutes; then seek help. Never with PDE-5 inhibitors (sildenafil, tadalafil): severe hypotension, syncope, ischaemia.

• Nitrate tolerance: efficacy returns only after nitrates have been absent for several hours (nitrate-free interval).

Traps the Examiner Sets

• ACE-inhibitor cough is from bradykinin and resolves when the drug is stopped.

• ACE inhibitors and ARBs are contraindicated in pregnancy and in bilateral renal artery stenosis.

• Amlodipine is contraindicated in heart failure (ICMR) and causes ankle oedema.

• Never ACE inhibitor + ARB; ARNI needs 36 hours off an ACE inhibitor.

• Beta-blockers in heart failure only after decongestion, started low.

• Nitrates + sildenafil = dangerous hypotension.

• Hypertensive urgency: oral drugs, slow lowering, no IV.

Memory Hooks & Shortcuts

Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.

• 🧠 140/90 twice, 160/100 once — ICMR diagnosis of hypertension

• 🧠 A + T, then T↑, A↑, add C, then S — ICMR protocol: amlodipine, telmisartan, chlorthalidone, spironolactone

• 🧠 Two RAAS = Renal disaster — never combine ACE inhibitor and ARB

• 🧠 ACE = Always Coughs Eventually — bradykinin cough with ACE inhibitors

• 🧠 Pregnant? Pull the pril and sartan — RAAS drugs are fetotoxic

• 🧠 Drain, then Defend — heart failure: decongest with furosemide, then ARNI, spironolactone, beta-blocker, SGLT2 inhibitor

• 🧠 Nitrate + Viagra = Floor — PDE-5 inhibitors with nitrates cause severe hypotension

Rapid-Revision Cards

• HTN grades (ICMR)

  G1 140–159/90–99 · G2 160–179/100–109 · G3 ≥ 180/110.

• HTN diagnosis

  ≥ 140/90 on 2 visits, or ≥ 160/100 at one.

• BP targets

  < 140/90; < 130/80 DM/CKD/CVD; < 150/90 at ≥ 80.

• First step (ICMR)

  Two classes, single pill: CCB or thiazide-like + ACEi/ARB.

• ICMR protocol 1

  Amlo 5 → +Telmi 40 → Telmi 80 → Amlo 10 → +Chlorthalidone 12.5 → MRA; 4-weekly.

• Never

  ACEi + ARB together.

• Amlodipine

  Avoid in heart failure; pedal oedema.

• ACEi

  Dry cough (bradykinin), angioedema, hyperkalaemia; not in pregnancy or bilateral RAS.

• RAAS + pregnancy

  Boxed fetal toxicity: stop when pregnancy found.

• Thiazide-like

  Avoid in gout, pregnancy; low K and Na, high Ca and glucose.

• HTN urgency

  ≥ 180/120, no organ damage: oral drugs, lower over 24–48 h, no IV.

• Hydralazine

  Drug-induced lupus.

• Methyldopa

  Coombs-positive haemolytic anaemia.

• Nitroprusside

  Cyanide; max rate ≤ 10 min.

• HF first step (ICMR)

  IV furosemide to decongest.

• HF drugs (ICMR)

  ARNI + spironolactone; beta-blocker after decongestion; SGLT2 inhibitor.

• ARNI switch

  36-hour gap from ACEi.

• Spironolactone

  Hyperkalaemia, gynaecomastia.

• Ivabradine

  Blocks HCN (If) current.

• Angina symptom control (ICMR)

  Metoprolol ± DHP CCB; add nitrates.

• Angina prevention (ICMR)

  Aspirin 75 (clopidogrel if intolerant) + high-intensity statin + ACEi.

• SL nitroglycerin

  Every 5 min, max 3 in 15 min.

• Nitrates + PDE-5

  Contraindicated: severe hypotension.

• Nitrate tolerance

  Needs a nitrate-free interval.

• Verapamil + beta-blocker

  Ventricular depression, AV block.

• Furosemide

  Ototoxicity, worse with aminoglycosides.

Sources

Facts in this article were checked against these documents.

• Standard Treatment Workflow: Hypertension in Adults — Indian Council of Medical Research / Department of Health Research, MoHFW, May 2026

• Standard Treatment Workflows: Heart Failure; Stable Angina — Indian Council of Medical Research / Department of Health Research, MoHFW, January 2026

• Prescribing labels: Vasotec, Cozaar, Entresto, Aldactone, Farxiga, Nitrostat, isosorbide mononitrate ER, Corlanor, hydralazine, methyldopa, sodium nitroprusside, verapamil ER, amlodipine, furosemide — DailyMed, US National Library of Medicine, current labels, accessed November 2026 (link)

• Competency Based Undergraduate Curriculum, Pharmacology (PH 4.1–4.5) — National Medical Commission, 2024

Test Yourself: Practice Questions

Twenty-five questions in NEET PG style, most of them clinical vignettes.

Practice Questions (NEET PG pattern)

Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.

Q1. A 45-year-old has BP 150/95 on two visits; no other illness. Under ICMR 2026, the usual starting treatment is

• (a) clonidine

• (b) furosemide

• (c) two drugs from different classes (e.g. amlodipine with an ARB), preferably as a single pill

• (d) a beta-blocker alone

Q2. Hypertension can be diagnosed at a single clinic visit (ICMR) when BP is at least

• (a) 180/120 only

• (b) 130/80

• (c) 160/100

• (d) 140/90

Q3. The ICMR BP target for a 60-year-old with diabetes is

• (a) below 120/70 at any cost

• (b) below 160/100

• (c) below 150/90

• (d) below 130/80 if tolerated

Q4. A woman on enalapril develops a persistent dry cough. The mechanism and best switch are

• (a) bradykinin accumulation; it resolves when the ACE inhibitor is stopped

• (b) histamine release; add an antihistamine

• (c) beta-blockade; it is permanent

• (d) fluid overload; add furosemide

Q5. A hypertensive woman on losartan finds she is 8 weeks pregnant. The right action is to

• (a) add enalapril

• (b) double the dose

• (c) continue losartan

• (d) stop losartan as soon as possible (fetal toxicity)

Q6. ACE inhibitors and ARBs are contraindicated in

• (a) heart failure

• (b) type 2 diabetes

• (c) bilateral renal artery stenosis

• (d) post-MI patients

Q7. A man with heart failure is started on amlodipine for hypertension. Under ICMR this is

• (a) inappropriate: heart failure is listed as a contraindication to the CCB

• (b) required with every ARNI

• (c) safe only with digoxin

• (d) the best choice

Q8. A patient's BP stays high on amlodipine and telmisartan. Under ICMR, a doctor should never add

• (a) chlorthalidone

• (b) spironolactone later

• (c) a lifestyle plan

• (d) an ACE inhibitor, because combining two RAAS blockers raises kidney-injury risk

Q9. A man with gout needs a third antihypertensive. ICMR advises against

• (a) telmisartan

• (b) amlodipine

• (c) metoprolol

• (d) chlorthalidone (thiazide-like diuretic)

Q10. BP is 190/122 in an asymptomatic man with no signs of organ damage (hypertensive urgency). ICMR advises

• (a) IV labetalol bolus

• (b) no treatment

• (c) oral antihypertensives, lowering BP gradually over 24–48 hours, no IV drugs

• (d) IV nitroprusside at once

Q11. A woman on hydralazine develops arthralgia, rash and a positive ANA. The likely cause is

• (a) rheumatoid arthritis

• (b) drug-induced lupus from hydralazine

• (c) ACE-inhibitor angioedema

• (d) methyldopa haemolysis

Q12. Long-term methyldopa can cause

• (a) lupus

• (b) a positive Coombs test and haemolytic anaemia

• (c) gynaecomastia

• (d) cough

Q13. A patient on a high-dose nitroprusside infusion for 2 days develops metabolic acidosis and confusion. Suspect

• (a) cyanide toxicity

• (b) beta-blocker overdose

• (c) thiazide hyponatraemia

• (d) digoxin toxicity

Q14. In acute decompensated heart failure, ICMR's first step is to

• (a) decongest with IV furosemide

• (b) start ivabradine

• (c) give verapamil

• (d) start a beta-blocker at full dose

Q15. In heart failure with reduced EF, a beta-blocker should be started

• (a) never

• (b) at full dose during acute pulmonary oedema

• (c) after decongestion, at a low dose, titrated every 1–2 weeks

• (d) only with verapamil

Q16. A patient on enalapril is to switch to sacubitril-valsartan. The required gap is

• (a) 7 days

• (b) no gap

• (c) 36 hours

• (d) 2 hours

Q17. Which drug, originally for diabetes, reduces CV death and heart-failure hospitalisation in heart failure?

• (a) Pioglitazone

• (b) Insulin

• (c) Dapagliflozin (SGLT2 inhibitor)

• (d) Glibenclamide

Q18. A man on spironolactone for heart failure develops painful breast enlargement and a potassium of 6.0. Both are

• (a) unrelated

• (b) signs of digoxin toxicity

• (c) known adverse effects of spironolactone

• (d) due to furosemide

Q19. Ivabradine lowers heart rate by blocking

• (a) the HCN channel carrying the pacemaker If current

• (b) L-type calcium channels

• (c) Na-K ATPase

• (d) beta-1 receptors

Q20. A man with stable angina took sildenafil last night and now has chest pain. Sublingual nitroglycerin is

• (a) first-line

• (b) safe at half dose

• (c) safe with aspirin

• (d) contraindicated: severe hypotension, syncope or ischaemia

Q21. During an angina attack, sublingual nitroglycerin may be taken

• (a) only after aspirin fails

• (b) every hour without limit

• (c) every 5 minutes, up to 3 tablets in 15 minutes, then seek help

• (d) once a day only

Q22. A patient on round-the-clock isosorbide mononitrate finds it stops working. The remedy is

• (a) switching to IV nitrates continuously

• (b) adding sildenafil

• (c) a daily nitrate-free interval

• (d) doubling the dose repeatedly

Q23. For symptom control in stable angina, ICMR starts with

• (a) ranolazine alone

• (b) digoxin

• (c) metoprolol with or without a dihydropyridine CCB

• (d) furosemide

Q24. A man with stable angina cannot tolerate aspirin. ICMR's alternative antiplatelet is

• (a) warfarin

• (b) heparin

• (c) no antiplatelet

• (d) clopidogrel 75 mg daily

Q25. A patient on metoprolol for angina is given verapamil. The risk is

• (a) hypertension

• (b) cough

• (c) hyperkalaemia

• (d) worsening ventricular function and AV block

Active Recall

From memory: give the ICMR 2026 hypertension grades, diagnosis rule, targets, first-line strategy and step-up protocol; list each class with its contraindications and side effects; outline heart-failure and stable-angina treatment under ICMR; and recall the label warnings for ACE inhibitors, ARNI, nitrates, hydralazine, methyldopa and nitroprusside.