II. Hypertension without Compelling Indications
INDICATIONS FOR DRUG THERAPY FOR ADULTS WITH HYPERTENSION WITHOUT COMPELLING INDICATIONS FOR SPECIFIC AGENTS
1) Antihypertensive therapy should be prescribed for average diastolic blood pressures of 100 mm Hg or higher (Grade A) or average systolic blood pressures of 160 mm Hg or higher (Grade A) in patients without macrovascular target organ damage or other cardiovascular risk factors (see Table 3 & 4 from accompanying CHEP Diagnosis paper).
2) Antihypertensive therapy should be strongly considered if diastolic blood pressure readings average 90 mm Hg or higher in the presence of macrovascular target organ damage or other independent cardiovascular risk factors (Grade A).
3) Antihypertensive therapy should be strongly considered if systolic blood pressure readings average 140 mm Hg or higher in the presence of macrovascular target organ damage (Grade C for 140 mm Hg to 160 mm Hg; Grade A for higher than 160 mm Hg).
4) (NEW) Antihypertensive therapy should be considered in all patients meeting the above indications regardless of age (Grade B). Caution should be exercised in elderly patients who are frail.
III. CHOICE OF THERAPY FOR ADULTS WITH HYPERTENSION WITHOUT COMPELLING INDICATIONS FOR SPECIFIC AGENTS
A Recommendations for individuals with diastolic ± systolic hypertension
1) Initial therapy should be monotherapy with a thiazide diuretic (Grade A); a beta-blocker (in patients younger than 60 years, Grade B); an ACE inhibitor (in non-blacks, Grade B); a longacting CCB (Grade B); or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C).
2) Additional antihypertensive drugs should be used if target blood pressure levels are not achieved with standard dose monotherapy (Grade B). Add-on drugs should be chosen from first line choices. Useful choices include a thiazide diuretic or CCB with either an ACE inhibitor, ARB or beta- blocker (Grade B for the combination of thiazide diuretic with a dihydropyridine CCB; Grade C for the combination of dihydropyridine CCB and ACE inhibitor; and Grade D for all other combinations). Caution should be exercised in combining a nondihydropyridine CCB and a beta-blocker (Grade D). (NEW) The combination of an ACE inhibitor and ARB is not recommended (Grade A).
3) Combination therapy using first line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target (Grade C). However, caution should be exercised in patients in whom a substantial fall in blood pressure is more likely or more poorly tolerated (e.g. elderly patients) from initial combination therapy.
4) If blood pressure is still not controlled with a combination of 2 or more first line agents, or there are adverse effects, other antihypertensive drugs may be added (Grade D).
5) Possible reasons for poor response to therapy (Table 2) should be considered (Grade D).
6) Alpha-blockers are not recommended as first-line agents for uncomplicated hypertension (Grade A); beta blockers are not recommended as first-line therapy for uncomplicated hypertension in patients aged 60 years or older(Grade A) and ACE inhibitors are not recommended as first-line therapy for uncomplicated hypertension in black patients (Grade A). However, these agents may be used in patients with certain comorbid conditions or in combination therapy.
B Recommendations for individuals with isolated systolic hypertension
1) Initial therapy should be monotherapy with a thiazide diuretic (Grade A); a long-acting dihydropyridine CCB (Grade B) or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C).
2) Additional antihypertensive drugs should be used if target blood pressure levels are not achieved with standard dose monotherapy (Grade B). Add-on drugs should be chosen from first-line choices (Grade D).
3) If blood pressure is still not controlled with a combination of two or more first-line agents, or there are adverse effects, other classes of drugs (such as alpha-blockers, ACE inhibitors, centrally acting agents or nondihydropyridine CCBs) may be added or substituted (Grade D).
4) Possible reasons for poor response to therapy (Table 2) should be considered (Grade D).
5) Alpha-blockers are not recommended as first-line agents for uncomplicated isolated systolic hypertension (Grade A), and beta-blockers are not recommended as first-line therapy for isolated systolic hypertension in patients aged 60 years or older (Grade A). However, both agents may be used in patients with certain comorbid conditions or in combination therapy.
IV. GLOBAL VASCULAR PROTECTION THERAPY FOR ADULTS WITH HYPERTENSION WITHOUT COMPELLING INDICATIONS FOR SPECIFIC AGENTS
1) Statin therapy is recommended in hypertensive patients with 3 or more cardiovascular risk factors as defined in (Table 4) (Grade A in patients older than 40 years) or with established atherosclerotic disease (Grade A regardless of age).
2) Strong consideration should be given to the addition of low dose ASA therapy in hypertensive patients (Grade A in patients older than 50 years). Caution should be exercised if blood pressure is not controlled (Grade C).
V. GOAL OF THERAPY FOR ADULTS WITH HYPERTENSION WITHOUT COMPELLING INDICATIONS FOR SPECIFIC AGENTS
1) The systolic blood pressure treatment goal is lower than 140 mm Hg (Grade C). The diastolic blood pressure treatment goal is lower than 90 mm Hg (Grade A).