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HTN Treatment Algorithm
HTN Treatment Algorithm
HTN Treatment Algorithm
Systolic BP Diastolic BP Based on the 2017 ACC/AHA Guideline for the Prevention, Detection,
BP Category (mmHg) (mmHg) Evaluation, and Management of High Blood Pressure in Adults
Stage 1 Hypertension 130-139 OR 80-89 Goal for all ages <65 years with hypertension, regardless
of chronic comorbidities, if tolerated is <130/80 mmHg
Thiazide diuretics • Chlorthalidone preferred: long half-life, evidence for CVD benefit
e.g. chlorthalidone, indapamide • HCTZ: may be cheaper, more widely available, more tolerable
hydrochlorothiazide, metolazone • Monitor electrolytes: hyponatremia, hypokalemia, uric acid, calcium
If BP is above goal
CCBs, non-dihydropyridines* • *Generally less preferred than the dihydropyridine CCBs
e.g. diltiazem, verapamil • Avoid regular use with BBs due to risk of bradycardia and heart block
• Do not use with HFrEF If BP is above goal • Titrate dose as tolerated
• Drug interactions: both are CYP3A4 substrates, moderate inhibitors
• If dosing is optimized then add
Secondary Medications • Titrate dose as tolerated additional drug; first use either
first-line agents, those preferred
Beta-blockers • May be first-line with compelling indication (e.g. IHD, post-MI, HF) • If dosing is optimized then add
for existing comorbidities, or
e.g. atenolol, metoprolol, carvedilol, • HFrEF preferred agents: metoprolol succinate, carvedilol, bisoprolol additional drug; first use either
bisoprolol, labetalol, nebivolol, etc. • Bronchospastic airway disease preferred: atenolol, metoprolol, bisoprolol based on tolerability
• Generally avoid use of BBs with intrinsic sympathomimetic activity first-line agents, those preferred
(e.g. acebutolol, pindolol, penbutolol), especially with IHD or HF for existing comorbidities, or • Do not combine ACEi, ARB, or
• Avoid abrupt cessation: risk of rebound tachycardia based on tolerability aliskiren
Loop diuretics • Preferred diuretics with symptomatic HF • Do not combine ACEi, ARB, or
furosemide, torsemide, bumetanide • Preferred over thiazides with significant CKD (GFR <30 mL/min)
aliskiren
K-sparing diuretics • Minimal antihypertensive effect; used to protect from hypokalemia
triamterene, amiloride • Avoid in patients with significant CKD (GFR <45 mL/min)
Aldosterone antagonists • Preferred add-on with resistant HTN and in primary aldosteronism
spironolactone, eplerenone • K-sparing diuretic effect: avoid with K-sparing diuretics, or CKD
• Spironolactone > risk of gynecomastia, impotence than eplerenone Reference: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/
ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention,
Alpha-1 blockers • May be considered second-line in those with concomitant BPH Detection, Evaluation, and Management of High Blood Pressure in Adults: A
doxazosin, prazosin, terazosin • Risk for orthostatic hypotension, especially in older adults
Report of the American College of Cardiology/American Heart Association Task
• Use w/ a diuretic and BB: causes fluid retention and reflex tachycardia
Force on Clinical Practice Guidelines [published correction appears in J Am Coll
Direct vasodilators
hydralazine, minoxidil • Hydralazine has risk of drug-induced lupus-like syndrome Cardiol. 2018 May 15;71(19):2275-2279]. J Am Coll Cardiol.
• Minoxidil has risk of hirsutism and requires use with a loop diuretic 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006
Central alpha-2 agonists • Generally last-line due to CNS adverse effects, orthostatic hypotension More clinical pearls at pyrls.com
clonidine, guanfacine, methyldopa • Avoid abrupt cessation: risk of rebound hypertension (esp. clonidine)
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