BP CLASSIFICATION	SBP* MMHG	DBP* MMHG	LIFESTYLE MODIFICATION	INITIAL DRUG THERAPY
BP CLASSIFICATION	SBP* MMHG	DBP* MMHG	LIFESTYLE MODIFICATION	WITHOUT COMPELLING INDICATION	WITH COMPELLING INDICATION (See Table1)
NORMAL	< 120	and < 80	Encourage	No antihypertensive drug indicated.	Drug(s) for compelling indications.‡
PREHYPERTENSION	120-139	or 80-89	Yes	No antihypertensive drug indicated.	Drug(s) for compelling indications.‡
STAGE 1 HYPERTENSION	140-159	or 90-99	Yes	Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.	Drug(s) for the compelling indications.‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
STAGE 2 HYPERTENSION	≥ 160	or ≥ 100	Yes	Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

DBP, diastolic blood pressure; SBP, systolic blood pressure.
Drug abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;
BB, beta-blocker; CCB, calcium channel blocker.

*	Treatment determined by highest BP category.
†	Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡	Treat patients with chronic kidney disease or diabetes to BP goal of < 130/80 mmHg.

Table1: Clinical trial and guideline basis for compelling indications for individual drug classes.

Compelling Indications*	Recommended Drugs †
Compelling Indications*	Diuretic	BB	ACEI	ARB	CCB	Aldo ANT
Heart Failure
Postmyocardial Infarction
High Coronary Disease Risk
Diabetes
Chronic Kidney Disease
Recurrent Stroke Prevention
Postmyocardial infarction

*	Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with the BP.
†	Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker.

Treatment of Hypertension

Goals of Therapy

The ultimate public health goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality. Since most persons with hypertension, especially those age >50 years, will reach the DBP goal once SBP is at goal, the primary focus should be on achieving the SBP goal. Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD complications. In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmHg.

Lifestyle Modifications

Adoption of healthy lifestyles by all persons is critical for the prevention of high BP and is an indispensable part of the management of those with hyper-tension. Major lifestyle modifications shown to lower BP include weight reduction in those individuals who are overweight or obese, adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan which is rich in potassium and calcium, dietary sodium reduction, physical activity, and moderation of alcohol consumption. Lifestyle modifications reduce BP, enhance antihypertensive drug efficacy, and decrease cardiovascular risk. For example, a 1,600 mg sodium DASH eating plan has effects similar to single drug therapy. Combinations of two (or more) lifestyle modifications can achieve even better results.

Pharmacologic Treatment

There are excellent clinical outcome trial data proving that lowering BP with several classes of drugs, including angiotensin converting enzyme inhibitors(ACEIs), angiotensin receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), and thiazide-type diuretics, will all reduce the complications of hypertension. Thiazide-type diuretics have been the basis of antihypertensive therapy in most outcome trials. In these trials, including the recently published Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial(ALLHAT), diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension. The exception is the Second Australian National Blood Pressure trial which reported slightly better outcomes in White men with a regimen that began with an ACEI compared to one starting with a diuretic. Diuretics enhance the antihypertensive efficacy of multidrug regimens, can be useful in achieving BP control, and are more affordable than other antihypertensive agents. Despite these findings, diuretics remain underutilized.

Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes (ACEIs, ARBs, BBs, CCBs) demonstrated to be beneficial in randomized controlled outcome trials. The list of compelling indications requiring the use of other antihypertensive drugs as initial therapy. If a drug is not tolerated or is contraindicated, then one of the other classes proven to reduce cardiovascular events should be used instead.

Lifestyle Modifications to Manage Hypertension

Modification	Recommendation	Approximate SBP Reduction (Range)
Weight reduction	Maintain normal body weight. (body mass index 18.5–24.9 kg/m2).	5–20 mmHg/10 kg weight loss
Adopt DASH eating plan	Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat.	8–14 mmHg
Dietary sodium reduction	Reduce dietary sodium intake to no more than 100 mmol per day. (2.4 g sodium or 6 g sodium chloride).	2–8 mmHg
Physical activity	Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week).	4–9 mmHg
Moderation of alcohol	Limit consumption to no more than consumption 2 drinks (1 oz or 30 mL ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons.	2–4 mmHg

DASH, Dietary Approaches to Stop Hypertension.

Oral Antihypertensive Drugs

Class	Drug (Trade Name)
Thiazide diuretics	Hydrochlorothiazide
Loop diuretics	Furomide
Potassium-sparing diuretics	Amiloride
Aldosterone receptor blockers	Spironolactone
BBs	Atenolol Betaxolol Bisoprolol Metoprolol Sotalol Propranolol
Conbined alpha-and BBs	Carvedilol Labetalol
ACEIs	Captopril Enalapril Fosinopril Lisinopril Perindopril Ramipril
Angiotensin II antagonists	Candersartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan
CCBs – non-dihydropyridines	Diltiazem extended release Verapamil long acting Verapamil nifedipine
CCBs – dihydropyridines Amlodipine	Felodipine Nicardipine sustained release Nifedipine long-acting
Alpha-1 blockers	Doxazosin Prazosin
Central alpha-2 agonists and other centrally acting drugs	Methyldopa
Direct vasodilators	Minoxidil

Combination Drugs for Hypertension

Combination Type	Fixed-Dose Combination, mg
ACEIs and diuretics	Captopril-hydrochlorothiazide
ARBs and diurectics	Candesartan-hydrochlorothiazide Irbesartan-hydrochlorothiazide Losartan-hydrochlorothiazide Olmesartan-hydrochlorothiazide telmisartan-hydrochlorothiazide valsartan-hydrochlorothiazide
BBs and diuretics	Atenolol-chlorthalidone bisoprolol-chlorthalidone
Diuretic and diuretic	Amiloride-hydrochlorothiazide spironolactone-hydrochlorothiazide
ARBs and CCBs	Amlodipine-valsartan

*	Drug abbreviations: BB, beta-blocker; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker.

Alogorithm for Treatment of Hypertension

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