The long-awaited US guideline for hypertension has been published in JAMA and contains the following recommendations:
1. In the general population aged ≥60 years, initiate drug treatment at systolic BP ≥150 mmHg or diastolic BP ≥90 mmHg and aim for SBP <150 mmHg and DBP <90 mmHg.
2. In the general population <60 years, initiate drug treatment at DBP ≥90mmHg and treat to DBP <90 mmHg).
3. In the general population <60 years, initiate drug treatment at SBP ≥140 mmHg and treat to SBP <140 mm Hg.
4. In the population aged ≥18 years with chronic kidney disease (CKD), initiate drug treatment at SBP ≥140 mmHg or DBP ≥90 mmHg and treat to SBP <140mm Hg and DBP <90mm Hg.
5. In the population aged ≥18 years with diabetes, initiate drug treatment at SBP ≥140 mmHg or DBP ≥90 mmHg and treat to SBP <140 mmHg and goal DBP <90 mmHg.
6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB).
7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.
8. In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.
9. The main objective of hypertension treatment is to attain and maintain goal BP but if this is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed.
An accompanying editorial notes that even though these guidelines are generally based on a rigorous assessment of the available clinical trial evidence for treatment of high blood pressure, some elements of these guidelines may be controversial and most likely will spark discussion. Two other related editorials provide perspectives about these recommendations in the broader context of effect on clinical care and policy.
NICE guidance on hypertension was published in 2011.