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

Guidelines for Individuals with Isolated Systolic Hypertension

1. Initial therapy should be single agent therapy with a thiazide/thiazide-like diuretic (Grade A), a long-acting dihydropyridine CCB (Grade A) 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/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 options (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 (Supplemental Table S10) should be considered (Grade D).
5. α-Blockers are not recommended as first-line agents for uncomplicated hypertension (Grade A); β-blockers are not recommended as first-line therapy for isolated systolic hypertension in patients aged 60 years of age or older (Grade A). However, both agents may be used in patients with certain co morbid conditions or in combination therapy.