What is the first treatment step for low risk hypertension?

The algorithm begins with lifestyle modifications for 3 to 6 months. If these measures are ineffective, treatment proceeds to monotherapy with an ACE inhibitor, an angiotensin II receptor blocker, a calcium channel blocker or a thiazide diuretic.

Which medicines can be used as monotherapy for hypertension?

The monotherapy options shown in the algorithm are an ACE inhibitor, an angiotensin II receptor blocker, a calcium channel blocker or a thiazide diuretic.

When is dual therapy used for hypertension?

Dual therapy is the initial pharmacological strategy for moderate and high cardiovascular risk. In low risk patients, it is introduced when lifestyle measures, monotherapy, dose escalation and switching the initial medicine do not provide adequate control.

When is triple therapy used for hypertension?

Triple therapy is used when dual therapy remains ineffective in patients with moderate or high cardiovascular risk. In the very high risk pathway, the algorithm begins directly with triple therapy.

What is added for hypertension uncontrolled by triple therapy?

The algorithm recommends quadruple therapy by adding spironolactone, a beta blocker or another second line agent to the triple combination.

When is renal denervation considered in this hypertension algorithm?

Renal denervation is considered in the very high risk pathway when triple therapy and subsequent quadruple therapy remain ineffective.

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Therapeutic Algorithm - Hypertension

Therapeutic Algorithm for the Management of Hypertension

Article written and reviewed by Dr Luca Moretti

Risk Stratification

Low Risk

Lifestyle modifications (3-6 months)

If ineffective

Monotherapy (choose one: ACE inhibitor, sartan, calcium channel blocker, thiazide diuretic)

If ineffective

Increase dosage

If ineffective

Switch drug

If ineffective

Dual Therapy (ACE inhibitor/sartan + calcium channel blocker/thiazide diuretic)

Moderate Risk

Dual Therapy (ACE inhibitor/sartan + calcium channel blocker/thiazide diuretic)

If ineffective

Increase dosage

If ineffective

Switch one drug

If ineffective

Triple Therapy (Dual + the missing agent: thiazide diuretic or calcium channel blocker)

High Risk

Dual Therapy (ACE inhibitor/sartan + calcium channel blocker/thiazide diuretic)

If ineffective

Increase dosage

If ineffective

Switch one drug

If ineffective

Triple Therapy (Dual + the missing agent: thiazide diuretic or calcium channel blocker)

If ineffective

Quadruple Therapy (Triple + spironolactone or beta-blockers or other second-line agent)

Very High Risk

Triple Therapy (Dual + the missing agent: thiazide diuretic or calcium channel blocker)

If ineffective

Quadruple Therapy (Triple + spironolactone or beta-blockers or other second-line agent)

If ineffective

Renal denervation

References

Williams B, et al. 2023 ESH Guidelines for the management of arterial hypertension. Journal of Hypertension. 2023;41(6):1103-1182.
McEvoy JW, et al. 2023 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal. 2023;44(33):2777-2879.
Mancia G, et al. Practice guidelines for arterial hypertension management: 2023 update. Journal of Hypertension. 2023;41(6):1163-1199.
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2018;71(6):e13-e115.
Chobanian AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.
Burnier M, et al. Drug adherence in hypertension: current status and future perspectives. Current Hypertension Reports. 2022;24(1):1-11.
Musini VM, et al. Pharmacotherapy for hypertension in adults aged 60 or older. Cochrane Database of Systematic Reviews. 2019;6:CD011528.
Weber MA, et al. Clinical practice guidelines for the management of hypertension in the community. Journal of Clinical Hypertension. 2014;16(1):14-26.
Italian Society of Arterial Hypertension. ESH 2023 Guidelines for the Treatment of Arterial Hypertension. 2023.
Thomopoulos C, et al. Effects of blood pressure lowering on outcome incidence in hypertension: 4. Effects of various classes of antihypertensive drugs. Journal of Hypertension. 2015;33(2):195-211.

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