Hypertension: Treatment Algorithm

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HYPERTENSION TREATMENT ALGORITHM

 Principles of hypertension treatment:

 • JNC-7 treatment goal is BP <140/90mmHg
(BP <130/80mmHg in patients with diabetes
or chronic kidney disease).

 • ADA treatment goal for patients with diabetes
is <140/80mmHg (<130 may be appropriate
for certain younger patients).

 • Most patients will need two medications to
reach goal.

                   
        Lifestyle Modifications        
                   
        Not at goal BP        
                   
        Initial Drug Choices        
                   
           
    without compelling indications      with compelling indications   
                 
               
 

Stage 1 Hypertension
(Systolic BP 140−159mmHg or diastolic BP 90−99mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB, or combination.

 

Stage 2 Hypertension
(Systolic BP ≥160mmHg or diastolic BP ≥100mmHg)
2-drug combination for most (usually thiazide-type diuretic and ACEI, ARB, BB, or CCB).

 

Drug(s) for the compelling indications (see below)
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

 
           
                   
        Not at Goal Blood Pressure        
                   
    Optimize dosages or add additional drugs until goal BP is achieved. Consider consultation with hypertension specialist.    
                   
COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES
Compelling indication Initial therapy options

Heart failure

thiazide diuretic, beta blocker, ACEI, ARB, aldosterone antagonist

Post myocardial infarction

beta blocker, ACEI, aldosterone antagonist

High CVD risk

thiazide diuretic, beta blocker, ACEI, calcium channel blocker

Diabetes

thiazide diuretic, beta blocker, ACEI, ARB, calcium channel blocker

Chronic kidney disease

ACEI, ARB

Recurrent stroke prevention

thiazide diuretic, ACEI

STRATEGIES FOR IMPROVING ADHERENCE TO THERAPY

 • Clinician empathy increases patient trust, motivation, and adherence to therapy.

 • Clinicians should consider patients' cultural beliefs and individual attitudes in formulating therapy.

CAUSES OF RESISTANT HYPERTENSION

• Improper BP measurement

• Excessive sodium intake

• Inadequate diuretic therapy

• Excessive alcohol intake

• Identifiable causes of 
hypertension

• Medication:

Inadequate doses

Drug actions and interactions (eg, nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)

Over-the-counter drugs and dietary supplements

NOTES

Key: CVD = cardiovascular disease;  ARB = angiotensin II receptor blocker;  ACEI = angiotensin converting enzyme (ACE) inhibitor;  BB = beta blocker;  CCB = calcium channel blocker

REFERENCES

For Adults age 18 years and older. Adapted from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 5/03 (NIH Publication No. 03‑5231).

Standards of Medical Care in Diabetes—2013. Diabetes Care. January 2013; 36:S11−S66; doi:10.2337/dc13-S011.

(Rev. 7/2015)

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