Treatment algorithm

Your Organisational Guidance

ebpracticenet urges you to prioritise the following organisational guidance:

Cardiovasculaire risicobepaling in de eerste lijnPublished by: Domus MedicaLast published: 2020Évaluation du risque cardiovasculaire en première lignePublished by: Domus MedicaLast published: 2010

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: stage 1 hypertension and lower CVD risk and without diabetes

1st line – lifestyle modification and monitoring

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: stage 1 hypertension and lower CVD risk and without diabetes
1st line – 

lifestyle modification and monitoring

In patients with stage 1 hypertension, cardiovascular disease (CVD) risk assessment tools are used to guide initial approach to therapy and whether the patient should receive antihypertensive medication or can be managed with lifestyle modifications.[1][2][4]​​​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) guideline recommends using the Pooled Cohort Equations to assess 10-year atherosclerotic CVD risk.​​ [ ASCVD Risk Estimator Plus Opens in new window ] ​​ The PREVENT™ calculator is also available; this is a newer calculator from the AHA that estimates the 10- and 30-year risk of total CVD for people aged 30 years and older. [ PREVENT™ online calculator Opens in new window ]

Patients with stage 1 hypertension and low risk of CVD may be managed initially with lifestyle modifications and re-assessed in 3-6 months.​[2][109]

Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by the physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] per day in hypertensive women). Total weekly alcohol consumption should not exceed 140 g for men and 80 g for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Patients presenting with stage 2 hypertension should receive antihypertensive therapy (in addition to lifestyle modification) regardless of CVD risk.[1][2][4]

without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes

1st line – thiazide diuretic

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
1st line – 

thiazide diuretic

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.[2]

The ACC/AHA guideline recommends antihypertensive therapy for patients with diabetes or a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥10%.[2] [ ASCVD Risk Estimator Plus Opens in new window ] ​​​ The PREVENT™ calculator is also available; this is a newer calculator from the AHA that estimates the 10- and 30-year risk of total CVD for people aged 30 years and older. [ PREVENT™ online calculator Opens in new window ]

In several large clinical trials, no other agents have proven superior to thiazide (or thiazide-like) diuretics as monotherapy for achieving goal reductions in BP.[114]

May be most effective in older people and black people. Preferred initial therapy in black people.[2]

Given their once-daily dosing, minor adverse-effect profile, and relatively low cost, thiazide diuretics are recommended in people with diabetes without increased albumin excretion. In diabetes plus increased albumin excretion, ACE inhibitors or angiotensin-II receptor antagonists are recommended. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study showed that chlorthalidone, amlodipine, or lisinopril were co-equal for mild hypertension in type 2 diabetes.[114]

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects. If a low-to-moderate dose is not effective to reach goal, dose may be optimised or a second drug added. There is insufficient evidence about which approach is superior.

Primary options

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

OR

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

OR

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​​[99][100][101]​​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

1st line – ACE inhibitor or angiotensin-II receptor antagonist

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
1st line – 

ACE inhibitor or angiotensin-II receptor antagonist

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.​[2]​ The ACC/AHA guideline recommends antihypertensive therapy for patients with diabetes or a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥10%.[2] [ ASCVD Risk Estimator Plus Opens in new window ] ​​​ The PREVENT™ calculator is also available; this is a newer calculator from the AHA that estimates the 10- and 30-year risk of total CVD for people aged 30 years and older. [ PREVENT™ online calculator Opens in new window ]

ACE inhibitors or angiotensin-II receptor antagonists may be effective in younger, especially white patients. A thiazide (or thiazide-like) diuretic or calcium-channel blocker is preferred in black people.[2]

In patients with diabetes who have increased albumin excretion, ACE inhibitors or angiotensin-II receptor antagonists are recommended. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study showed that chlortalidone, amlodipine, or lisinopril were co-equal for mild hypertension in type 2 diabetes.[114] ACE inhibitors are renoprotective, decreasing the progression of proteinuria in patients with diabetes.[116]

Not recommended in pregnancy; therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects. If a low-to-moderate dose is not effective to reach goal, dose may be optimised or a second drug added. There is insufficient evidence about which approach is superior.

Once-daily doses may be preferred as they simplify dosing regimens and improve adherence.[105]

Primary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

OR

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

OR

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

OR

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

OR

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

OR

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

OR

azilsartan: 40-80 mg orally once daily

OR

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia. 

1st line – calcium-channel blocker

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
1st line – 

calcium-channel blocker

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.​[2]​ The ACC/AHA guideline recommends antihypertensive therapy for patients with diabetes or a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥10%.[2] [ ASCVD Risk Estimator Plus Opens in new window ] ​​​ The PREVENT™ calculator is also available; this is a newer calculator from the AHA that estimates the 10- and 30-year risk of total CVD for people aged 30 years and older. [ PREVENT™ online calculator Opens in new window ]

Calcium-channel blockers are peripheral vasodilators.

May be most effective in older people and black people. Preferred initial therapy in black people.[2]

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study showed that chlortalidone, amlodipine, or lisinopril were co-equal for mild hypertension in type 2 diabetes.[114]

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects. If a low-to-moderate dose is not effective to reach goal, dose may be optimised or a second drug added. There is insufficient evidence about which approach is superior.

Primary options

amlodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

OR

felodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

OR

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day

OR

diltiazem: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

1st line – ACE inhibitor or angiotensin-II receptor antagonist + thiazide diuretic or calcium-channel blocker

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
1st line – 

ACE inhibitor or angiotensin-II receptor antagonist + thiazide diuretic or calcium-channel blocker

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.​[2]​ The ACC/AHA guideline recommends antihypertensive therapy for patients with diabetes or a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥10%.[2] [ ASCVD Risk Estimator Plus Opens in new window ] ​​​ The PREVENT™ calculator is also available; this is a newer calculator from the AHA that estimates the 10- and 30-year risk of total CVD for people aged 30 years and older. [ PREVENT™ online calculator Opens in new window ]

Combination, low-dose therapy with an ACE inhibitor or angiotensin-II receptor antagonist plus a thiazide (or thiazide-like) diuretic or calcium-channel blocker is an alternative first-line option to monotherapy. [ Cochrane Clinical Answers logo ]

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[1][105]

Primary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

or

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

or

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

or

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

or

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

or

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

or

azilsartan: 40-80 mg orally once daily

or

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

-- AND --

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

or

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

or

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

or

amlodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

felodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day

or

diltiazem: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

1st line – thiazide diuretic + ACE inhibitor or angiotensin-II receptor antagonist

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 not at goal with monotherapy or stage 2
1st line – 

thiazide diuretic + ACE inhibitor or angiotensin-II receptor antagonist

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 2 hypertension as BP ≥140/90 mmHg.​[2]​ Patients presenting with stage 2 hypertension will require more than one drug for BP control. Therefore, the initiation of two concurrent antihypertensives of different classes is recommended.

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[1][105]

Primary options

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

or

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

or

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

-- AND --

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

or

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

or

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

or

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

or

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

or

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

or

azilsartan: 40-80 mg orally once daily

or

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 not at goal with monotherapy or stage 2
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

1st line – ACE inhibitor or angiotensin-II receptor antagonist + calcium-channel blocker

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 not at goal with monotherapy or stage 2
1st line – 

ACE inhibitor or angiotensin-II receptor antagonist + calcium-channel blocker

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 2 hypertension as BP ≥140/90 mmHg.​[2]​ Patients presenting with stage 2 hypertension will require more than one drug for BP control. Therefore, the initiation of two concurrent antihypertensives of different classes is recommended.

Calcium-channel blockers are peripheral vasodilators.

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[1][105]

Primary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

or

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

or

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

or

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

or

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

or

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

or

azilsartan: 40-80 mg orally once daily

or

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

-- AND --

amlodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

felodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day

or

diltiazem: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
|
stage 1 not at goal with monotherapy or stage 2
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

concomitant chronic coronary disease without congestive heart failure

1st line – beta-blocker or ACE inhibitor or angiotensin-II receptor antagonist

Back
ACUTE
|
concomitant chronic coronary disease without congestive heart failure
|
stage 1 hypertension
1st line – 

beta-blocker or ACE inhibitor or angiotensin-II receptor antagonist

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.[2]

Guidelines recommend a beta-blocker, ACE inhibitor, or angiotensin-II receptor antagonist for patients with chronic coronary disease (CCD) and hypertension.[1][2][127]

A beta-blocker offers cardioprotective effects in patients with CCD, decreasing myocardial wall stress and lessening myocardial oxygen demand. Different agents vary in lipid solubility, selectiveness for beta-2 receptors, intrinsic sympathomimetic activity, and alpha-blocker activity. Metoprolol and bisoprolol are beta-1 selective, while carvedilol is a combined alpha- and non-selective beta-blocker.

Following abrupt cessation of therapy with certain beta-blockers, exacerbations of angina pectoris and, in some cases, myocardial infarction have occurred. All beta-blockers should be tapered over 1-2 weeks and patients should be monitored for symptoms of angina.

Initial dose of antihypertensive medicines depends on clinical situation; medicines are titrated for a therapeutic effect, while observing for potential adverse effects.

Many patients with CCD also take nitrates, which act as an exogenous nitric oxide donor. Modest reductions in systolic BP can be observed, but the US Food and Drug Administration has not approved the use of nitrates solely as antihypertensive therapy.

Initial dose of antihypertensive medicines depends on clinical situation; medicines are titrated for a therapeutic effect, while observing for potential adverse effects.

Primary options

metoprolol: 50 mg/day orally (immediate-release) given in 2 divided doses initially, increase gradually according to response, maximum 200 mg/day

OR

bisoprolol: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

OR

carvedilol: 6.25 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 50 mg/day

OR

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

OR

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

OR

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

OR

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

OR

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

OR

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

OR

azilsartan: 40-80 mg orally once daily

OR

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic coronary disease without congestive heart failure
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

1st line – beta-blocker + ACE inhibitor or angiotensin-II receptor antagonist

Back
ACUTE
|
concomitant chronic coronary disease without congestive heart failure
|
stage 1 not at goal with monotherapy or stage 2
1st line – 

beta-blocker + ACE inhibitor or angiotensin-II receptor antagonist

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 2 hypertension as BP ≥140/90 mmHg.[2]

​Following abrupt cessation of therapy with certain beta-blockers, exacerbations of angina pectoris and, in some cases, myocardial infarction have occurred. All beta-blockers should be tapered over 1-2 weeks and patients should be monitored for symptoms of angina.

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[1][105]

Primary options

metoprolol: 50 mg/day orally (immediate-release) given in 2 divided doses initially, increase gradually according to response, maximum 200 mg/day

or

bisoprolol: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

carvedilol: 6.25 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 50 mg/day

-- AND --

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

or

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

or

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

or

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

or

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

or

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

or

azilsartan: 40-80 mg orally once daily

or

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic coronary disease without congestive heart failure
|
stage 1 not at goal with monotherapy or stage 2
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

Consider – addition of calcium-channel blocker and/or thiazide diuretic and/or aldosterone antagonist

Back
ACUTE
|
concomitant chronic coronary disease without congestive heart failure
|
stage 1 not at goal with monotherapy or stage 2
Consider – 

addition of calcium-channel blocker and/or thiazide diuretic and/or aldosterone antagonist

Additional treatment recommended for SOME patients in selected patient group

Dihydropyridine calcium-channel blockers, thiazide diuretics, and/or aldosterone antagonists are added as required to further control hypertension.[1][2][127]

Primary options

amlodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

felodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day

-- AND / OR --

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

or

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

or

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

-- AND / OR --

spironolactone: 25 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day

or

eplerenone: 50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

concomitant heart failure (HF)

1st line – guideline-directed medical therapy for HF

Back
ACUTE
|
concomitant heart failure (HF)
1st line – 

guideline-directed medical therapy for HF

Recommended medications for HF also lower BP; however, HF guidelines note that clinical trials assessing the impact of BP reduction on outcomes in patients with hypertension and HF are lacking and that the optimal BP goal and antihypertensive regimen are not known.[131][132]​​

Heart failure with reduced ejection fraction (HFrEF):

Treatment of HFrEF (left ventricular EF<40%) is similar in hypertensive and normotensive patients. For most patients with HFrEF, a combination of drugs from the following four medication classes should be started initially and continued long-term:[131][132] 

Renin-angiotensin system inhibitors (angiotensin receptor-neprilysin inhibitor [ARNi], ACE inhibitor, or an angiotensin-II receptor antagonist)

Beta-blockers

Aldosterone receptor antagonists (mineralocorticoid receptor antagonists)

Sodium-glucose co-transporter 2 (SGLT2) inhibitors.

Patients who have signs of congestion and volume overload are also prescribed diuretics.

Additionally, the combination of hydralazine and a nitrate (e.g., isosorbide dinitrate/hydralazine) has been shown to be of benefit for black patients who have persistent symptoms despite receiving optimal medical therapy, as well as in all patients with HF who cannot receive ACE inhibitors, angiotensin-II receptor antagonists, or ARNi because of intolerance or contraindications.[131][132]

Non-dihydropyridine calcium-channel blockers are not recommended for the treatment of hypertension in adults with HFrEF.[2]

For more information, see Heart failure with reduced ejection fraction.

Heart failure with preserved ejection fraction (HFpEF):

HFpEF is defined as symptoms and signs of heart failure, with left ventricular EF ≥50%.[133]​ Diuretics should be used to control hypertension in patients with comorbid HFpEF who present with symptoms of volume overload.[2]

While optimal BP goal and antihypertensive regimens are not known for patients with HFpEF, the American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) guideline on the management of HF advises that ACE inhibitors, angiotensin-II receptor antagonists, aldosterone antagonists, and possibly ARNi could be first-line agents to control BP, given experience with their use in HFpEF trials.[131] Similarly, a 2023 expert consensus document from the ACC suggests that, in addition to diuretics, patients with hypertension and HFpEF can be treated with ARNis, angiotensin-II receptor antagonists, and aldosterone antagonists.[134]

SGLT2 inhibitors (which have demonstrated BP-lowering effects) are also now recommended in the US and European guidelines for all patients with HFpEF.[131][134][135]​ 

For more information, see Heart failure with preserved ejection fraction.

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant heart failure (HF)
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy. Lifestyle modifications should be lifelong.[1][2][53]​[64]​​[99][100][101]​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <40 inches (<102 cm) for men and <35 inches (<88 cm) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] per day in hypertensive women). Total weekly alcohol consumption should not exceed 140 g for men and 80 g for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

concomitant left ventricular hypertrophy without chronic coronary disease

1st line – angiotensin-II receptor antagonist or ACE inhibitor

Back
ACUTE
|
concomitant left ventricular hypertrophy without chronic coronary disease
1st line – 

angiotensin-II receptor antagonist or ACE inhibitor

Angiotensin-II receptor antagonists have been shown to promote regression of left ventricular hypertrophy.[176]

An ACE inhibitor may be used as a second-line option.

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects. Once-daily doses may be preferred as they simplify dosing regimens and improve adherence.[105]

Primary options

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

OR

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

OR

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

OR

azilsartan: 40-80 mg orally once daily

OR

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

Secondary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

OR

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

OR

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant left ventricular hypertrophy without chronic coronary disease
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and  Hypertriglyceridaemia.

concomitant chronic renal disease without cardiovascular disease

1st line – ACE inhibitor or angiotensin-II receptor antagonist

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 hypertension
1st line – 

ACE inhibitor or angiotensin-II receptor antagonist

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.​[2]

ACE inhibitors are first-line therapy for comorbid renal disease, with angiotensin-II receptor antagonists as an alternative.[137]​ Continuing ACE inhibitor or angiotensin-II receptor antagonist therapy may be associated with cardiovascular benefit as kidney function declines.[138] A dose adjustment may be required in patients with renal impairment.

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Once-daily doses may be preferred as they simplify dosing regimens and improve adherence.[105]

The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guideline for management of BP in chronic kidney disease (CKD) recommends that patients with CKD are treated to a target systolic BP <120 mmHg, specifying that this should be measured using standardised office (clinic) BP measurement, preferably automated office BP.[137] The ACC/AHA guideline recommends treating patients with CKD to a target of <130/80 mmHg.[2]

Some drugs should be used with caution in patients with renal impairment and a dose adjustment may be required. Some drugs may also be contraindicated in patients with renal impairment. Consultation with a nephrology specialist should be considered. See Chronic kidney disease.

Primary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

OR

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

OR

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

OR

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

Secondary options

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

OR

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

OR

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

OR

azilsartan: 40-80 mg orally once daily

OR

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

OR

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

2nd line – calcium-channel blocker

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 hypertension
2nd line – 

calcium-channel blocker

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.​[2]

Calcium-channel blockers are peripheral vasodilators.

Non-dihydropyridine calcium-channel blockers (i.e., diltiazem, verapamil) may be indicated if there is proteinuria.[141]

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Primary options

amlodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

OR

felodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

OR

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day

OR

diltiazem: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

OR

verapamil: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104] ​See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

2nd line – thiazide diuretic

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 hypertension
2nd line – 

thiazide diuretic

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 1 hypertension as BP 130-139/80-89 mmHg.​[2]

Thiazide (or thiazide-like) diuretics may not be as effective if glomerular filtration rate is <20 mL/minute/1.73m².

In the CLICK trial, in patients with advanced CKD and poorly controlled hypertension, chlortalidone therapy improved BP control at 12 weeks compared with placebo.[139]

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Primary options

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

OR

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

OR

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 hypertension
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and  Hypertriglyceridaemia.

1st line – ACE inhibitor or angiotensin-II receptor antagonist + thiazide diuretic

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 not at goal with monotherapy or stage 2
1st line – 

ACE inhibitor or angiotensin-II receptor antagonist + thiazide diuretic

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 2 hypertension as BP ≥140/90 mmHg.​[2]

ACE inhibitors are first-line therapy for comorbid renal disease, with angiotensin-II receptor antagonists as an alternative. Continuing ACE inhibitor or angiotensin-II receptor antagonist therapy may be associated with cardiovascular benefit as kidney function declines.[138] A dose adjustment may be required in patients with renal impairment.

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Thiazide (or thiazide-like) diuretics may not be as effective if glomerular filtration rate is <20 mL/minute/1.73m².

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[1][105]

Primary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

or

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

or

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

-- AND --

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

or

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

or

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

Secondary options

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

or

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

or

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

or

azilsartan: 40-80 mg orally once daily

or

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

-- AND --

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

or

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

or

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 not at goal with monotherapy or stage 2
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

2nd line – ACE inhibitor or angiotensin-II receptor antagonist + calcium-channel blocker

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 not at goal with monotherapy or stage 2
2nd line – 

ACE inhibitor or angiotensin-II receptor antagonist + calcium-channel blocker

The classification of blood pressure (BP) differs between guidelines.[1][2][4]​​ The American College of Cardiology (ACC)/American Heart Association (AHA) defines stage 2 hypertension as BP ≥140/90 mmHg.​[2]

ACE inhibitors are first-line therapy for comorbid renal disease with angiotensin-II receptor antagonists as an alternative. A dose adjustment may be required in patients with renal impairment.

ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of child-bearing potential because approximately half of pregnancies are unplanned, pregnancies may occur with oral contraceptive use, and there is a risk of fetopathy when ACE inhibitor or angiotensin-II receptor antagonist therapy continues into the second trimester.

Calcium-channel blockers are peripheral vasodilators. Non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) may be indicated if there is proteinuria.[141][143]

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[1][105]

Primary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

or

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

or

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

-- AND --

amlodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

felodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day

or

diltiazem: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

or

verapamil: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

Secondary options

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

or

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

or

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

or

azilsartan: 40-80 mg orally once daily

or

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

-- AND --

amlodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

felodipine: 2.5 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day

or

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day

or

diltiazem: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

or

verapamil: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 not at goal with monotherapy or stage 2
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104] See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

3rd line – ACE inhibitor or angiotensin-II receptor antagonist + thiazide diuretic + aldosterone antagonist

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 not at goal with monotherapy or stage 2
3rd line – 

ACE inhibitor or angiotensin-II receptor antagonist + thiazide diuretic + aldosterone antagonist

Spironolactone may further reduce proteinuria when added to an ACE inhibitor or angiotensin-II receptor antagonist, but also raises the risk of hyperkalaemia.[142][143]​​ Spironolactone is usually added to an ACE inhibitor or angiotensin-II receptor antagonist, after a thiazide diuretic has been added to minimise hyperkalaemia. Eplerenone can be used as an alternative.

Spironolactone and eplerenone are contraindicated in patients with anuria or severe renal impairment.

Primary options

lisinopril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day

or

enalapril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

benazepril: 5-10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses

or

perindopril: 4 mg orally once daily initially, increase gradually according to response, maximum 16 mg/day as a single dose or in 2 divided doses

or

ramipril: 1.25 to 2.5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day as a single dose or in 2 divided doses

-- AND --

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

or

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

or

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

-- AND --

spironolactone: 25 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day

or

eplerenone: 50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

Secondary options

candesartan: 8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day

or

irbesartan: 75-150 mg orally once daily initially, increase gradually according to response, maximum 300 mg/day

or

losartan: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

or

azilsartan: 40-80 mg orally once daily

or

telmisartan: 20-40 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

or

valsartan: 80-160 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day

-- AND --

hydrochlorothiazide: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day

or

chlortalidone: 12.5 mg orally once daily initially, increase gradually according to response, maximum 25 mg/day

or

indapamide: 1.25 mg orally once daily initially, increase gradually according to response, maximum 2.5 mg/day

-- AND --

spironolactone: 25 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day

or

eplerenone: 50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day as a single dose or in 2 divided doses

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant chronic renal disease without cardiovascular disease
|
stage 1 not at goal with monotherapy or stage 2
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​[99][100][101]​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

concomitant atrial fibrillation without other comorbidity

1st line – beta-blocker

Back
ACUTE
|
concomitant atrial fibrillation without other comorbidity
1st line – 

beta-blocker

Atenolol and metoprolol are beta-1 selective. Atenolol is generally less cardioprotective and has less BP-lowering effects compared with other members of this class.[177]

Following abrupt cessation of therapy with certain beta-blockers, exacerbations of angina pectoris, and, in some cases, myocardial infarction have occurred. All beta-blockers should be tapered over 1-2 weeks and patients should be monitored for symptoms of angina.

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects. A dose adjustment may be required with atenolol in patients with renal impairment.

Primary options

metoprolol: 50 mg/day orally (immediate-release) given in 2 divided doses initially, increase gradually according to response, maximum 200 mg/day

OR

atenolol: 25-50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant atrial fibrillation without other comorbidity
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104] See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

2nd line – calcium-channel blocker

Back
ACUTE
|
concomitant atrial fibrillation without other comorbidity
2nd line – 

calcium-channel blocker

Non-dihydropyridine calcium-channel blockers (e.g., verapamil, diltiazem) are associated with negative inotropy and slowing of atrioventricular conduction.

Frequently used in the treatment of supraventricular tachycardia or atrial arrhythmias/rapid ventricular response.

Avoid in people with decreased ejection fraction (<50%).

Initial dose of antihypertensive medications depends on clinical situation; medications are titrated for a therapeutic effect, while observing for potential adverse effects.

Primary options

diltiazem: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

OR

verapamil: 120-180 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 480 mg/day

Plus – lifestyle and CVD risk factor modification

Back
ACUTE
|
concomitant atrial fibrillation without other comorbidity
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

ONGOING

refractory/resistant to optimised triple therapy at any stage

1st line – individualised therapy

Back
ONGOING
|
refractory/resistant to optimised triple therapy at any stage
1st line – 

individualised therapy

Managing recalcitrant hypertension requires expertise. Frequently requiring multiple antihypertensive agents, patients must be observed and counselled regarding adverse effects, medication adherence, potential drug-drug interactions, and metabolic abnormalities. Infrequently, patients will require a screen for secondary causes of hypertension.

Representative agents of the main treatment class options, including ACE inhibitors, angiotensin-II receptor antagonists, and calcium-channel blockers should be maximised. An optimally dosed thiazide-like diuretic, such as chlortalidone or indapamide, should be used over hydrochlorothiazide.[155] ACE inhibitors and angiotensin-II receptor antagonists should not be used together due to the risk of acute renal failure.

The fourth-line drug option is generally spironolactone. Eplerenone can be used as an alternative. Spironolactone and eplerenone are contraindicated in patients with hyperkalaemia. Caution should be used in patients with renal impairment; either a dose adjustment may be required, or the drug may be contraindicated depending on the severity of renal impairment, indication for use (i.e., hypertension versus heart failure), and local guidance. Concomitant administration with potassium-sparing diuretics is contraindicated.

Otherwise, a fourth- or fifth-line option is a peripheral adrenergic blocker. Hydralazine is a less-preferred option due to its twice-daily dosing requirement and increased risk of oedema with simultaneous calcium-channel blocker treatment. Minoxidil may rarely be indicated in patients with advanced chronic kidney disease; however its use requires some expertise in anticipating and managing adverse effects of fluid retention. Combined alpha- and beta-blockers (e.g., carvedilol, labetalol) are also considerations. Additionally, physicians with expertise in managing difficult patients have had niche success using a combination of a dihydropyridine calcium-channel blocker with a non-dihydropyridine calcium-channel blocker (e.g., amlodipine plus diltiazem). Clonidine is generally avoided because of its adverse-effect profile.

The most important principles for managing the challenging patient are:

1) Promotion of medication adherence using the principle of pill reduction (i.e., use of single pill, fixed-dose combination formulations or avoidance of twice-daily dose regimens when possible)

2) Maximising the dose of the diuretic (preferably chlortalidone or indapamide)

3) Use of spironolactone as a fourth drug when appropriate.[156]

It is also important to question the patient's alcohol use and offer lifestyle counselling; structured diet and exercise programmes can lower BP in patients with resistant hypertension.[157][158]

Referral to a specialist in hypertension should be considered.

Plus – lifestyle and CVD risk factor modification

Back
ONGOING
|
refractory/resistant to optimised triple therapy at any stage
Plus – 

lifestyle and CVD risk factor modification

Treatment recommended for ALL patients in selected patient group

All patients should be given a thorough explanation of the risks associated with hypertension and the need for adequate control and adherence to therapy.

Lifestyle modifications should be lifelong.[1][2][53]​[64]​​​​[99][100][101]​​​​​​​ Modification should include: sodium reduction (≤1.5 g/day); potassium supplementation (3.5 to 5.0 g/day), preferably by consumption of a potassium-rich diet unless contraindicated; Dietary Approaches to Stop Hypertension (DASH) diet (8-10 servings of fruit and vegetables daily, whole grains, low sodium, low-fat proteins); maintaining waist circumference of <102 cm (<40 inches) for men and <88 cm (<35 inches) for women and weight loss to a body mass index of about 25 kg/m²; increased physical activity consisting of at least 30 minutes of moderate-intensity, dynamic aerobic exercise (walking, jogging, cycling, or swimming) 5 days per week to total 150 minutes/week, as tolerated or recommended by physician; limited alcohol consumption (≤2 standard drinks [<20-30 g alcohol] per day in hypertensive men, ≤1 standard drink [<10-20 g alcohol] in hypertensive women). Total weekly alcohol consumption should not exceed 14 standard drinks (140 g) for men and 8 standard drinks (80 g) for women.

In addition to lifestyle modifications for weight loss, anti-obesity pharmacotherapy and metabolic surgery may be considered in select patients with comorbid obesity, to treat obesity and prevent or attenuate hypertension.[104]​ See Obesity in adults.

Smoking cessation should always be encouraged as well, to promote general vascular health, though smoking cessation has not been associated with decreased BP. See Smoking cessation.

Management of other modifiable CVD risk factors, such as concomitant dyslipidaemia, is also recommended in adults with hypertension.[1][2][64]​ Lipid-lowering therapy may be initiated based on estimated CV risk. See Hypercholesterolaemia, and Hypertriglyceridaemia.

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