Pharmacological Treatment

The thresholds for pharmacological treatment are controversial and vary depending on age (see “Hypertension in older adults”); the following recommendations are based on the 2017 ACC/AHA guidelines.

• Adults with SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg and ≥ 1 of the following:

  • Clinical ASCVD (e.g., ischemic heart disease, peripheral artery disease, or previous stroke) or congestive heart failure (CHF)

  • 10-year ASCVD risk ≥ 10% (includes age ≥ 65 years and diabetes mellitus)

• All adults with SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg

Choice of initial medication should be based on the following:

• Patient's initial blood pressure

  • SBP 130–139 mm Hg or DBP 80–89 mm Hg (stage 1 hypertension): Consider initial monotherapy.

  • SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg AND an average blood pressure > 20/10 mm Hg above target

    • Initiate combination therapy.

    • Commonly used combinations are an ACEI or ARB PLUS either a dihydropyridine CCB OR a thiazide-type diuretic.

• Additional factors to consider

  • Major comorbidities

  • Major contraindications

  • Adverse effects that may be unacceptable to patients

  • Patient race: For Black patients (including individuals with diabetes) without CHF or CKD, initial antihypertensive therapy should include a thiazide-type diuretic or CCB.