Treatment of Hypertension
Full update January 2023
For antihypertensive dosing information and more, see our charts, ACE Inhibitor Antihypertensive Dose Comparison, Comparison of Angiotensin Receptor Blockers, Comparison of Commonly Used Diuretics, Comparison of Calcium Channel Blockers, and Comparison of Oral Beta-Blockers. Note that blood pressure control in hypertensive crises, and acute ischemic stroke are covered in our charts, Drug Options for Hypertensive Emergency, and Acute Ischemic Stroke Pharmacotherapy Checklist.
Question |
Answer/Pertinent Information |
What lifestyle changes are recommended? |
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How should BP be measured? |
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How is hypertension diagnosed? |
***On ABPM, mean awake BP ≥135/≥85 mm Hg, or mean 24-hr BP ≥130/80 mm Hg, is high. Using HBPM, the patient should average two readings each morning and evening for seven days and discard the first day’s measurements. Mean BP ≥135/85 mm Hg is high.3,16 These metrics are not validated in US populations, and should be interpreted cautiously.6 |
What are some other roles for out-of-office BP monitoring? |
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Who should be treated with pharmacotherapy based on the ACC/AHA guidelines? |
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Who should be treated with pharmacotherapy based on the JNC 8 guidelines? |
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Who should be treated with pharmacotherapy based on the Hypertension Canada guidelines? |
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Who should be treated with pharmacotherapy based on the Int Soc HTN guidelines? |
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What are BP goals based on ACC/AHA guidelines? For goals in patients with diabetes, see the DIABETES section, below. |
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What are BP goals based on JNC 8 guidelines? |
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What are BP goals based on Hypertension Canada guidelines? |
*Target SBP <120 mm Hg is not appropriate for patients with secondary HTN, adherence problems, or standing SBP <110 mm Hg, or if SBP cannot be measured accurately. There is limited or no evidence for this target in patients with LVEF <35%, MI within the past three months, patients with an indication for but not receiving a BB, or institutionalized elderly. Evidence is inconclusive for this target for patients with DM, history of stroke, or eGFR <20 mL/min/1.73 m2. Consider risk of side effects (e.g., orthostatic hypotension, acute kidney injury, electrolyte disturbances), and life expectancy (patients with less than three years were excluded from SPRINT).7 |
What are BP goals based on the Int Soc HTN guidelines? |
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How can BP goals be individualized? |
Age
Comorbidities
Other considerations
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What pharmacotherapy is recommended for uncomplicated hypertension? For treatment options for patients with diabetes, see DIABETES section, below. |
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What pharmacotherapy is recommended for hypertension based on patient-specific compelling indications? |
Notes:
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Treatment of HTN in Patients With Diabetes |
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What is the goal BP in patients with DM? |
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What are the ACC/AHA BP goals for patients with DM based on? |
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Treatment of HTN in Patients With Diabetes |
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What are ADA BP goals for patients with DM based on? |
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What are Hypertension Canada BP goals for patients with DM based on? |
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What are the Diabetes Canada BP goals for patients with DM based on? |
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What are the Diabetes Canada BP goals for patients with DM based on? |
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Treatment of HTN in Patients With Diabetes |
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What are the Int Soc HTN BP goals for patients with DM based on? |
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Why doesn’t intensive BP reduction show clear benefit in patients with DM? |
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Which antihypertensives are recommended for patients with DM? |
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Treatment of Resistant HTN |
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What is resistant hypertension? |
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What are some causes of resistant hypertension? |
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What nondrug interventions can be recommended to address resistant hypertension? |
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How do you optimize first-line antihypertensives in the treatment of resistant hypertension? |
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Does treatment of resistant hypertension lead to better outcomes? |
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What add-on antihypertensives (i.e., fourth-line, etc) can be considered for resistant hypertension? |
Note: Although not indicated for HTN, SGLT2 inhibitors (e.g., dapagliflozin) reduce BP and could be added at any time in appropriate patients with DM, CKD, or HF.25 |
Meds that Can Increase Blood Pressure
Drug/Drug Class |
Pertinent Information |
Acetaminophen |
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Alcohol |
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Antidepressants |
Bupropion
Monoamine oxidase inhibitors (MAOIs [e.g., phenelzine, tranylcypromine])30,31
Selective serotonin-norepinephrine reuptake inhibitors (SNRIs)
Selective serotonin reuptake inhibitors (SSRIs)
Tricyclic antidepressants
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Caffeine |
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Calcineurin inhibitors (e.g., cyclosporine, tacrolimus) |
Cyclosporine
Tacrolimus
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Cocaine |
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Corticosteroids |
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Decongestants |
Phenylephrine: unlikely to raise BP at recommended doses [Evidence Level C].40
Pseudoephedrine: may raise BP by about 1 to 2 mm Hg [Evidence Level C].41
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Dietary supplements |
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Erythropoietin |
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Estrogen |
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Nonsteroidal anti-inflammatory drugs (NSAIDs) |
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Stimulants, prescription |
Attention-deficit-hyperactivity-disorder (ADHD) medications
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Testosterone |
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Vascular endothelial growth factor inhibitors (e.g., bevacizumab, sorafenib) |
Bevacizumab
Sorafenib
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- SPRINT criteria: ≥50 years of age and SBP 130 to 180 mm Hg, with CV disease other than stroke, CKD,* 10-year CV risk ≥15%per Framingham, or age ≥75 years. (*Nondiabetic nephropathy, proteinuria <1 g/day, and eGFR 20 to 59 mL/min/1.73 m2 per the MDRD equation. Patients with more advanced CKD, polycystic kidney disease, or glomerulonephritis were excluded from SPRIINT.7
- “Thiazide” includes thiazide-like diuretics. Long-acting agents (chlorthalidone, indapamide) are preferred due to positive outcomes data.3,6,16,20,21,23
Abbreviations: ACC = American College of Cardiology; ACEI = angiotensin-converting enzyme inhibitor; ACS = acute coronary syndrome; AHA = American Heart Association; ABPM = ambulatory blood pressure monitoring; ARB = angiotensin receptor blocker; BB = beta-blocker; BP = blood pressure; CAD = coronary artery disease; CCB = calcium channel blocker; CKD = chronic kidney disease; CNS = central nervous system; CV = cardiovascular; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; DBP = diastolic blood pressure; HBPM= home blood pressure monitoring; HF = heart failure; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; HTN = hypertension; Int Soc HTN = International Society of Hypertension; MI = myocardial infarction; NSAID = nonsteroidal anti-inflammatory drug; JNC 8 = Eighth Joint National Committee; RAAS = renin-angiotensin-aldosterone system; RCT = randomized controlled trial; SBP = systolic blood pressure; SGLT2 = sodium-glucose transporter 2.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
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B |
Inconsistent or limited-quality patient-oriented evidence.* |
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C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]
References
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Cite this document as follows: Clinical Resource, Treatment of Hypertension. Pharmacist’s Letter/Prescriber’s Letter. February 2023. [390127]