Approach to antihypertensive drug therapy: Patients without indications for a specific drug (Inset 1)

BP: blood pressure; ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; ACR: albumin-to-creatinine ratio; CKD: chronic kidney disease; ESKD: end-stage kidney disease; HFpEF: heart failure with preserved ejection fraction; ARNI: angiotensin receptor-neprilysin inhibitor; HFrEF: heart failure with reduced ejection fraction.
* In patients with stage 1 hypertension (ie, BP 130 to 139/80 to 89 mmHg) and elevated cardiovascular risk, attaining the goal BP with lifestyle interventions alone can be attempted for a period of 3 to 6 months. Drug therapy should be initiated in such patients if lifestyle interventions are not sufficient to achieve the BP goal.
¶ Some experts and consensus recommendations suggest that initial drug therapy should include 2 drugs (ie, combination therapy) if the systolic pressure is >20 mmHg above goal or the diastolic pressure is >10 mmHg above goal. However, other experts and consensus guidelines suggest that initial combination therapy be used in patients whose systolic pressure is >10 mmHg above the goal. Both approaches are reasonable.
Δ Dihydropyridine calcium channel blockers include drugs such as amlodipine, felodipine, extended-release nifedipine, nitrendipine, and levamlodipine.
◊ Using single-pill combinations (rather than prescribing 2 separate pills) is preferred because this can improve adherence and control.
§ Use of a thiazide-like diuretic (ie, chlorthalidone, indapamide) is a reasonable alternative for monotherapy or in combination with an ACE inhibitor or ARB (instead of using a dihydropyridine calcium channel blocker). In addition, a thiazide-like diuretic is preferred in certain patients (refer to inset 1). Thiazide-like diuretics (ie, chlorthalidone and indapamide) are more potent than thiazide-type diuretics (eg, hydrochlorothiazide). In addition, thiazide-like diuretics, but not thiazide-type diuretics, have been shown to reduce cardiovascular outcomes.
¥ ACE inhibitors or ARBs can prevent progression of CKD and reduce the risk of ESKD among patients with ACR ≥300 mg/g.
‡ Patients with severe asymptomatic hypertension (eg, blood pressure ≥180 mmHg systolic and/or ≥110 mmHg diastolic with no symptoms or signs of acute end-organ damage) should be evaluated for medication titration within 1 week.