Hypertension without Compelling Indications

Indications for drug therapy for adults with hypertensions without compelling indications for specific agents

1. Antihypertensive therapy should be prescribed for average diastolic blood pressures of 100 mmHg or higher (Grade A), or average systolic blood pressures of 160 mmHg or higher (Grade A) in patients without macrovascular target organ damage or other cardiovascular risk factors.
2. Antihypertensive therapy should be strongly considered if diastolic blood pressure readings average 90 mmHg or higher in the presence of macrovascular target organ damage or other independent cardiovascular risk factors (Grade A).
3. Antihypertensive therapy should be strongly considered if systolic blood pressure readings average 140 mmHg or higher in the presence of macrovascular target organ damage (Grade C for 140 mmHg to 160 mmHg; Grade A for higher than 160 mmHg).
4. Antihypertensive therapy should be considered in all patients meeting the above indications regardless of age (Grade B).  Caution should be exercised in elderly patients who are frail.

Choice of therapy for adults with hypertensions without compelling indications for specific agents

A Recommendations for Individuals with Diastolic ± Systolic Hypertension

1. Initial therapy should be monotherapy with a thiazide diuretic (Grade A); a beta-blocker (in patients younger than 60 years of age, Grade B); an ACE inhibitor (in nonblack patients, Grade B); a long-acting CCB (Grade B) or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C).
2. Additional antihypertensive drugs should be used if target blood pressure levels are not achieved with standard-dose monotherapy (Grade B). Add-on drugs should be chosen from first- line choices.  Useful choices include a thiazide diuretic or CCB with either an ACE inhibitor, ARB or beta-blocker (Grade B for the combination of thiazide diuretic and a dihydropyridine CCB; Grade C for the combination of dihydropyridine CCB and ACE inhibitor; and Grade D for all other combinations).  Caution should be exercised in combining a nondihydropyridine CCB and a beta-blocker (Grade D). The combination of an ACE inhibitor and ARB is not recommended (Grade A).
3. 3) Combination therapy using two first-line agents may also be considered as initial treatment of hypertension (Grade C) if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target.  However, caution should be exercised in patients in whom a substantial fall in blood pressure from initial combination therapy is more likely to occur or in whom it would be more poorly tolerated (e.g. elderly patients).
4. If blood pressure is still not controlled with a combination of 2 or more first line agents, or there are adverse effects, other antihypertensive drugs may be added (Grade D).
5. Possible reasons for poor response to therapy (Table 2) should be considered (Grade D).
6. Alpha-blockers are not recommended as first-line agents for uncomplicated hypertension (Grade A); beta-blockers are not recommended as first-line therapy for uncomplicated hypertension in patients 60 years of age or older (Grade A); and ACE inhibitors are not recommended as first-line therapy for uncomplicated hypertension in black patients (Grade A).  However, these agents may be used in patients with certain comorbid conditions or in combination therapy.

B Recommendations for individuals with isolated systolic hypertension

1. Initial therapy should be monotherapy with a thiazide diuretic (Grade A); a long-acting dihydropyridine CCB (Grade A) or an ARB (Grade B).  If there are adverse effects, another drug from this group should be substituted.  Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C).
2. Additional antihypertensive drugs should be used if target blood pressure levels are not achieved with standard-dose monotherapy (Grade B).  Add-on drugs should be chosen from first-line options (Grade D).
3. If blood pressure is still not controlled with a combination of two or more first-line agents, or there are adverse effects, other classes of drugs (such as alpha-blockers, ACE inhibitors, centrally acting agents or nondihydropyridine CCBs) may be added or substituted (Grade D).
4. Possible reasons for poor response to therapy (Table 2) should be considered (Grade D).
5. Alpha-blockers are not recommended as first-line agents for uncomplicated isolated systolic hypertension (Grade A); beta-blockers are not recommended as first-line therapy for isolated systolic hypertension in patients 60 years of age or older (Grade A). However, both agents may be used in patients with certain comorbid conditions or in combination therapy.

Global vascular protection for adults with hypertensions without compelling indications for specific agents

1. Statin therapy is recommended in hypertensive patients with 3 or more cardiovascular risk factors as defined in (Table 4) (Grade A in patients older than 40 years) or with established atherosclerotic disease (Grade A regardless of age).
2. 2) Strong consideration should be given to the addition of low-dose acetylsalicylic acid therapy in hypertensive patients (Grade A in patients older than 50 years).  Caution should be exercised if blood pressure is not controlled (Grade C).

Goal for therapy for adults with hypertensions without compelling indications for specific agents

1. The systolic blood pressure treatment goal is a pressure level of less than 140 mmHg (Grade C).  The diastolic blood pressure treatment goal is a pressure level of less than 90 mmHg (Grade A).