Guidelines for Cost-Effective Treatment of Hypertension in Adults
Community Health Network Pharmacy Council

I. Classes of Drugs That Are Available (see also, Dosage Regimens and Costs):

• thiazide and other diuretics
• beta blockers
• calcium channel blockers
• angiotensin-converting enzyme inhibitors
• angiotensin receptor antagonist(s)
• adrenergic antagonists and related drugs
• vasodilators
• antihypertensive combinations

II. Therapeutic Goals

Maintain arterial pressure below 140 mmHg SBP and 90 mmHg DBP. In patients with hypertension and diabetes or chronic kidney disease, the goal blood pressure is below 130/80.

The classification of hypertension has been restructured by the addition of pre-hypertension as a category and the consolidation of stage 2 and 3 hypertension. Based on the JNC VII guidelines [available in pdf], lifestyle modifications are recommended for all adults. Patients who are classified with pre-hypertension should be started on anti-hypertensive medications if they have the following indications: heart failure, diabetes, chronic kidney disease, recurrent strokes, high coronary disease risk, and post-myocardial infarction. Table of Classification and Management of Blood Pressure for Adults:

BP Classification	Systolic mmHg	Diastolic mmHg	Lifestyle Modification	Initial Drug Therapy
				Without Compelling Indication	With Compelling Indications
Normal	<120	and <80	Encourage	No antihypertensive drug indicated	Drug(s) for compelling indications (treat patients with diabetes or chronic kidney disease to BP goal of <130/80).
Prehypertension	120-139	or 80-89	Yes
Stage 1 Hypertension	140-159	or 90-99	Yes	Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB or combination	Drug(s) for compelling indications. Other anithypertensives (diuretics, ACEI, ARB, BB, CCB) as needed.
Stage 2 Hypertension	= or >160	= or >100	Yes	2-drug combination for most (thiazide with ACEI, ARB, BB or CCB)

Drug Abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, beta-blocker; CCB, calcium channel blocker

III. Treatment Algorithm for Uncomplicated Mild to Moderate Hypertension

IV. Pharmacologic Therapy for Special Clinical Situations

V. Antihypertensive Therapy -- Selected Adverse Effects

VI. Special Populations (Elderly, Pregnancy, Hypertensive Emergencies)

VII. Resistant Hypertension

VIII. Dosage Regimens and Costs

Last updated on June 29, 2007
Please send comments/corrections to nbenowitz[replace-with-@-sign]medsfgh.ucsf.edu or rita.lam[replace-with-@-sign]sfdph.org or brian.katcher[replace-with-@-sign]sfdph.org