Box. Recommendations for Management of Hypertension

Recommendation 1

In the general population aged _60 years, initiate pharmacologic treatment

to lower blood pressure (BP) at systolic blood pressure (SBP)_150

mmHg or diastolic blood pressure (DBP)_90mmHg and treat to a goal

SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation –

Grade A)

Corollary Recommendation

In the general population aged_60years, if pharmacologic treatment for

high BP results in lower achieved SBP (eg, <140mmHg) and treatment is

well tolerated and without adverse effects on health or quality of life, treatment

does not need to be adjusted. (Expert Opinion – Grade E)

Recommendation 2

In the general population <60 years, initiate pharmacologic treatment to

lowerBPatDBP_90mmHg and treat to a goalDBP<90mmHg. (For ages

30-59 years, Strong Recommendation – Grade A; For ages 18-29 years,

Expert Opinion – Grade E)

Recommendation 3

In the general population <60 years, initiate pharmacologic treatment to

lowerBPatSBP_140mmHg and treat to a goal SBP <140mmHg. (Expert

Opinion – Grade E)

Recommendation 4

In the population aged _18 years with chronic kidney disease (CKD), initiate

pharmacologic treatmentto lowerBPatSBP_140mmHgorDBP_90

mmHgandtreat to goalSBP<140mmHgandgoalDBP<90mmHg. (Expert

Opinion – Grade E)

Recommendation 5

In the populationaged_18years with diabetes, initiate pharmacologic treatmenttolowerBPatSBP

_140mmHgorDBP_90mmHgandtreat toagoal

SBP <140mmHg and goal DBP <90mmHg. (Expert Opinion –Grade E)

Recommendation 6

In the general nonblack population, including those with diabetes, initial

antihypertensive treatment should include a thiazide-type diuretic, calcium

channel blocker (CCB), angiotensin-converting enzyme inhibitor

(ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation

– Grade B)

Recommendation 7

In the general black population, including thosewith diabetes, initial antihypertensive

treatment should include a thiazide-type diuretic or CCB. (For

general black population: ModerateRecommendation –Grade B; for black

patients with diabetes:Weak Recommendation – Grade C)

Recommendation 8

In the population aged_18 years with CKD, initial (or add-on) antihypertensive

treatment should include an ACEI or ARB to improve kidney outcomes.

This applies toallCKDpatientswith hypertension regardless of race

or diabetes status. (Moderate Recommendation – Grade B)

Recommendation 9

The main objectiveofhypertension treatment is to attain and maintain goal

  1. If goalBPis not reached within amonthof treatment, increase the dose

of the initial drug or add a second drug from one of the classes in recommendation6(

thiazide-type diuretic,CCB,ACEI, or ARB).Theclinician should

continue to assess BP and adjust the treatment regimen until goal BP is

reached. If goal BP cannot be reached with 2 drugs, add and titrate a third

drug from the list provided.Donot use anACEI and anARBtogether in the

same patient. If goal BP cannot be reached using only the drugs in recommendation

6 because of a contraindication or the need to use more than 3

drugs to reach goal BP, antihypertensive drugs from other classes can be

used. Referral to a hypertension specialist may be indicated for patients in

whom goal BP cannot be attained using the above strategy or for the management

of complicated patients for whom additional clinical consultation

is needed. (Expert Opinion – Grade E)