HYPERTENSION TREATMENT ALGORITHM
Adults ≥18yrs with hypertension
Implement lifestyle modifications (continue throughout management)
Set blood pressure (BP) goal and initiate BP-lowering medication based on age, diabetes, and chronic kidney disease (CKD)
General population
(no diabetes or CKD)
Diabetes or CKD present
Age ≥60yrs Age <60yrs

• All ages

• With diabetes

• No CKD

• All ages

• CKD present w or w/o diabetes

BP Goal <150/90mmHg BP Goal <140/90mmHg BP Goal <140/90mmHg BP Goal <140/90mmHg
Non-black Black All races
Initiate thiazide-type diuretic, ACEI, ARB, or CCB, alone or in combinationa Initiate thiazide-type diuretic or CCB, alone or in combination Initiate ACEI or ARB, alone or in combination with other classa
Select drug treatment titration strategy:

A. Maximize first medication before adding second OR

B. Add second medication class before maximizing first medication OR

C. Start with two medication classes separately or as a fixed-dose combination

At goal?b Yes
No

• Reinforce medication and lifestyle adherence

• Strategy A or B: Add and titrate thiazide-type diuretic, ACEI, ARB, or CCB (use class not previously selected)a

• Strategy C: Maximize dose of initial regimen

At goal? Yes
No

• Reinforce medication and lifestyle adherence

• Add and titrate thiazide-type diuretic, ACEI, ARB, or CCB (use class not previously selected)a

At goal? Yes
No

• Reinforce medication and lifestyle adherence

• Add additional class (eg, β-blocker, aldosterone antagonist, or others not previously selected) and/or refer to hypertension specialist

No At goal? Yes Continue current therapy and monitoringc
FIRST LINE THERAPY FOR COMPELLING INDICATIONS
Compelling indication First-line Therapy

Heart failure

ACEI, ARB, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, diuretic, BB (carvedilol, metoprolol succinate, bisoprolol)

Post myocardial infarction

BBd (carvedilol, metoprolol, nadolol, bisoprolol, propranolol, timolol), ACEI, ARB

Diabetes

Thiazide diuretic, ACEI, ARB, CCB

Chronic kidney disease (CKD)

ACEI, ARB

Secondary stroke prevention

Thiazide diuretic, ACEI, ARB

LIFESTYLE MODIFICATIONS
Modification Recommendation Approximate SBP reduction

Weight loss

Aim for at least a 1kg reduction in body weight; best goal is ideal body weight

1mmHg/kg of weight loss

DASH diet (Dietary Approaches to Stop Hypertension)

Adopt a diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and total fat

3−11mmHg

Sodium reduction

Reduce dietary sodium intake by at least 1000mg/day; optimal goal is <1500mg/day

2−6mmHg

Potassium supplementation

Increase dietary potassium intake to 3500−5000mg/day. Four to five servings of fruits and vegetables will usually provide 1500−>3000mg of potassium

2−5mmHg

Physical activity

Increase physical activity:

• Aerobic exercise: 90−150mins/wk

2−8mmHg

• Dynamic resistance: 90−150mins/wk
(6 exercises, 3 sets/exercise, 10 repetitions/set)

2−4mmHg

• Isometric resistance: 3 sessions/wk for 8−10wks
(4 x 2min hand grips, 1min rest in between)

4−5mmHg

Reduced alcohol consumption

Limit to no more than 2 drinks/day in men and 1 drink/day in women (1 drink = 12oz beer, 5oz wine, 1.5oz distilled spirit)

3−4mmHg

Tobacco Cessation

Provide behavioral interventions. May need to consider pharmacotherapy for cessation

STRATEGIES TO IMPROVE TREATMENT ADHERENCE

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

• Clinicians should consider patients’ cultural beliefs and individual attitudes in formulating a treatment plan

• Simplifying medication regimens:

— Dosing to once daily rather than multiple times per day may improve adherence

— Use of fixed-dose combination agents rather than individual drug components

NOTES

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

a Avoid combination of ACEIs and ARBs.

b Wait 1 month before titrating.

c If BP goal not maintained, re-enter the algorithm where appropriate; individualize.

d Avoid atenolol or BB with intrinsic sympathomimetic activity.

REFERENCES

James PA, Oparil S, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017. doi: 10.1016/j.jacc.2017.11.006

(Rev. 4/2018)

This article originally appeared on MPR