Choice of Therapy for Adults with Hypertension Without Compelling Indications for Specific Agents

Recommendations for Individuals with Diastolic and/or Systolic Hypertension

1. Initial therapy should be with either monotherapy or single pill combination (SPC).
   1. Recommended monotherapy choices are:
      1. A thiazide/thiazide-like diuretic (Grade A), with longer-acting diuretics preferred (Grade B),
      2. A beta-blocker (in patients younger than 60 years; Grade B),
      3. An angiotensin converting enzyme (ACE) inhibitor (in non-black patients; Grade B),
      4. An angiotensin receptor blocker (ARB) (Grade B),
      5. A long-acting calcium channel blocker (CCB) (Grade B).
   2. Recommended SPC choices are those in which an ACE inhibitor is combined with a CCB (Grade A; new guideline), ARB with a CCB (Grade B) or ACE inhibitor or ARB with a diuretic (Grade B).
   3. Hypokalemia should be avoided in patients treated with a thiazide/thiazide-like 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/thiazide-like diuretic or CCB with either an ACE inhibitor, ARB or beta-blocker (Grade B for the combination of thiazide/thiazide-like diuretic and 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). The combination of an ACE inhibitor and an ARB is not recommended (Grade A).
3. If blood pressure is still not controlled with a combination of two or more first-line agents, or there are adverse effects, other antihypertensive drugs may be added (Grade D).
4. Possible reasons for poor response to therapy (Supplemental Table S10) should be considered (Grade D).
5. Alpha-blockers are not recommended as first-line agents for uncomplicated hypertension (Grade A); betablockers are not recommended as first-line therapy for uncomplicated hypertension in patients 60 years of age 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.