Treatment algorithm
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
stage 1 hypertension
Primary options
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
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.[78]
May be most effective in older people and black people. Preferred initial therapy in black people.[3]
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.[78]
The lowest dose should be titrated upward until a therapeutic effect is achieved or an adverse effect limits further titration. 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.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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 for men and <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] 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.
Primary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
OR
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
OR
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
OR
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
May be effective in younger, especially white patients. A thiazide (or thiazide-like) diuretic or calcium-channel blocker is preferred in black people.[3]
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 coequal for mild hypertension in type 2 diabetes.[78] ACE inhibitors are renoprotective, decreasing the progression of proteinuria in patients with diabetes.[80]
Not recommended in pregnancy, therefore, should generally be avoided in women of childbearing 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.
The lowest dose should be titrated upward until a therapeutic effect is achieved or an adverse effect limits further titration. 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.[75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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 for men and <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] 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.
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
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
Calcium-channel blockers are peripheral vasodilators.
May be most effective in older people and black people. Preferred initial therapy in black people.[3]
May be beneficial for some other patient groups; for example, those with Raynaud's disease, peripheral vascular disease, or coronary artery spasm.
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.[78]
The lowest dose should be titrated upward until a therapeutic effect is achieved or an adverse effect limits further titration. 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.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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 for men and <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] 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.
Primary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
or
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
-- AND --
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
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.
[ ]
ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of childbearing 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.
The lowest dose should be titrated upward until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] in hypertensive women). Total weekly alcohol consumption should not exceed 140 g for men and 80 g for women.
stage 1 not at goal with monotherapy or stage 2
Primary options
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
or
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
Primary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
or
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
irbesartan: 75 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
valsartan: 40-80 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
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
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 childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
stage 1 hypertension
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
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
Offers cardioprotective effects in patients with coronary artery disease (CAD). Decreases myocardial wall stress and lessens 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.
May be less well tolerated in patients with reactive airways disease (COPD, asthma).
[ ]
[ ]
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.
Many patients with CAD also take nitrates, which act as 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.[19]
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
Calcium-channel blockers are peripheral vasodilators.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Avoid combination of beta-blocker with non-dihydropyridine calcium-channel blockers (e.g., diltiazem or verapamil).
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
stage 1 not at goal with monotherapy or stage 2
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 --
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
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
Beta-blockers may be less well tolerated in patients with reactive airways disease (COPD, asthma).
[ ]
[ ]
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.
Calcium-channel blockers are peripheral vasodilators.
Avoid combination of beta-blocker with non-dihydropyridine calcium-channel blockers (e.g., diltiazem or verapamil).
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
or
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
Beta-blockers may be less well tolerated in patients with reactive airways disease (COPD, asthma).
[ ]
[ ]
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 childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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 --
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
Beta-blockers may be less well tolerated in patients with reactive airways disease (COPD, asthma).
[ ]
[ ]
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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
Primary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
or
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
-- AND --
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
Primary options
lisinopril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 2.5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses
or
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 150 mg/day
or
ramipril: 1.25 to 2.5 mg orally twice daily initially, increase gradually according to response, maximum 10 mg/day
-- AND --
carvedilol: 3.125 mg orally (regular-release) twice daily initially, increase gradually according to response, maximum 50 mg/day (or 100 mg/day in patients who weigh >85 kg)
or
metoprolol: 12.5 to 25 mg orally (extended-release) once daily 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
Secondary options
candesartan: 4-8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
valsartan: 20-40 mg orally twice daily initially, increase gradually according to response, maximum 320 mg/day
-- AND --
carvedilol: 3.125 mg orally (regular-release) twice daily initially, increase gradually according to response, maximum 50 mg/day (or 100 mg/day in patients who weigh >85 kg)
or
metoprolol: 12.5 to 25 mg orally (extended-release) once daily 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
Angiotensin-II receptor antagonists may be used if ACE inhibitors are not tolerated. ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of childbearing 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.
Metoprolol and bisoprolol are beta-1 selective beta-blockers; carvedilol is beta-1 and beta-2 selective and also has alpha-blocking properties. 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
Treatment recommended for SOME patients in selected patient group
Primary options
furosemide: 20-80 mg orally every 6-8 hours initially, increase gradually according to response, maximum 600 mg/day
OR
bumetanide: 0.5 to 2 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day
Secondary options
metolazone: 5-10 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day
Diuretics may be used for fluid overload.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Treatment recommended for SOME patients in selected patient group
Primary options
spironolactone: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day
OR
eplerenone: 25 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day
Aldosterone antagonists should be given to: patients with New York Heart Association functional class II to IV heart failure and ejection fraction <35%; or patients post-ST-elevation myocardial infarction with ejection fraction <40% and either symptomatic heart failure or comorbid diabetes. Blockade of aldosterone has been associated with decreased end-organ fibrosis.[94]
Treatment recommended for SOME patients in selected patient group
Primary options
isosorbide dinitrate/hydralazine: 20 mg (isosorbide dinitrate)/37.5 mg (hydralazine) orally three times daily initially, increase gradually according to response, maximum 120 mg (isosorbide dinitrate)/225 mg (hydralazine) per day
Isosorbide dinitrate/hydralazine may be useful for those intolerant to or refractory to other agents.
May offer additional mortality benefit in African American patients when added to optimised ACE inhibition plus beta-blockade plus aldosterone antagonism.[96]
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Primary options
furosemide: 20-80 mg orally every 6-8 hours initially, increase gradually according to response, maximum 600 mg/day
OR
bumetanide: 0.5 to 2 mg orally once daily initially, increase gradually according to response, maximum 10 mg/day
Secondary options
metolazone: 5-10 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day
Diuretics should be used to control hypertension in patients with comorbid heart failure with preserved ejection fraction (>45%) who present with symptoms of volume overload.[5]
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Treatment recommended for SOME patients in selected patient group
Primary options
lisinopril: 2.5 to 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 2.5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day as a single dose or in 2 divided doses
or
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 150 mg/day
or
ramipril: 1.25 to 2.5 mg orally twice daily initially, increase gradually according to response, maximum 10 mg/day
-- AND --
carvedilol: 3.125 mg orally (regular-release) twice daily initially, increase gradually according to response, maximum 50 mg/day (or 100 mg/day in patients who weigh >85 kg)
or
metoprolol: 12.5 to 25 mg orally (extended-release) once daily 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
Secondary options
candesartan: 4-8 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
valsartan: 20-40 mg orally twice daily initially, increase gradually according to response, maximum 320 mg/day
-- AND --
carvedilol: 3.125 mg orally (regular-release) twice daily initially, increase gradually according to response, maximum 50 mg/day (or 100 mg/day in patients who weigh >85 kg)
or
metoprolol: 12.5 to 25 mg orally (extended-release) once daily 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
If hypertension persists after the management of volume overload, ACE inhibitors or angiotensin-II receptor antagonists and beta-blockers should be used and titrated to achieve the target blood pressure goal.
Angiotensin-II receptor antagonists may be used if ACE inhibitors are not tolerated. ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and therefore should generally be avoided in women of childbearing 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.
Metoprolol and bisoprolol are beta-1 selective beta-blockers; carvedilol is beta-1 and beta-2 selective and also has alpha-blocking properties. 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 to 2 weeks, and patients should be monitored for symptoms of angina.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
Primary options
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
OR
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
Secondary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
OR
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
Angiotensin-II receptor antagonists have been shown to promote regression of left ventricular hypertrophy.[116]
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 childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration. Once-daily doses may be preferred as they simplify dosing regimens and improve adherence.[75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
stage 1 hypertension
Primary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
OR
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
OR
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
OR
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
ACE inhibitors and angiotensin-II receptor antagonists are not recommended in pregnancy and, therefore, should generally be avoided in women of childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
A dose adjustment may be required in patients with renal impairment.
Once-daily doses may be preferred as they simplify dosing regimens and improve adherence.[75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90-99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80-89 mmHg.[3][5]
Calcium-channel blockers are peripheral vasodilators.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
Primary options
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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
The classification of blood pressure (BP) differs between guidelines. For stage 1 hypertension, the Eighth Joint National Committee defines it as BP 140-159/90 to 99 mmHg and the American College of Cardiology/American Heart Association defines it as BP 130-139/80 to 89 mmHg.[3][5]
Thiazide (or thiazide-like) diuretics may not be as effective if glomerular filtration rate is <20 mL/minute/1.73m².
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
stage 1 not at goal with monotherapy or stage 2
Primary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
-- AND --
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
irbesartan: 75 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
valsartan: 40-80 mg orally once daily initially, increase gradually according to response, maximum 320 mg/day
-- AND --
hydrochlorothiazide: 12.5 to 25 mg/day orally once daily initially, increase gradually according to response, maximum 50 mg/day as a single dose or in 2 divided doses
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
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
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 childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
Primary options
lisinopril: 10 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
or
enalapril: 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
captopril: 25 mg orally twice daily initially, increase gradually according to response, maximum 200 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
Secondary options
candesartan: 4 mg orally once daily initially, increase gradually according to response, maximum 32 mg/day
or
irbesartan: 75 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
valsartan: 40-80 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
The classification of blood pressure (BP) differs between guidelines. For stage 2 hypertension, the Eighth Joint National Committee defines it as BP >160/100 mmHg and the American College of Cardiology/American Heart Association defines it as BP ≥140/90 mmHg.[3][5]
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 childbearing 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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
Some of these drugs are available in a fixed-dose combination formulation. These single pill formulations simplify dosing regimens and improve adherence.[2][75]
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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
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.[117]
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.
May be less well tolerated in patients with reactive airways disease (COPD, asthma).
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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
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.
The lowest dose should be titrated upwards until a therapeutic effect is achieved or an adverse effect limits further titration.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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.[104] 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 safe fourth- or fifth-line option is a peripheral adrenergic blocker. Hydralazine is a less-preferred option due its twice-daily dosing requirement and increased risk of oedema with simultaneous calcium-channel blocker treatment. Minoxidil is rarely required in patients with advanced chronic kidney disease and its use requires some expertise in anticipating and managing side-effects of fluid retention. Combined alpha- and beta-blockers (e.g., carvedilol, labetolol) 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 side-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.[105]
It is also important to question the patient's alcohol use and offer lifestyle counselling.
Referral to a specialist in hypertension should be considered.
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 and should include:[2][5][8][41][73][74] 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 in the presence of chronic kidney disease or use of medication that reduces potassium excretion; 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] 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.
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