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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
  1. Williams B, et al. 2023 ESH Guidelines for the management of arterial hypertension. Journal of Hypertension. 2023;41(6):1103-1182.
  2. McEvoy JW, et al. 2023 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal. 2023;44(33):2777-2879.
  3. Mancia G, et al. Practice guidelines for arterial hypertension management: 2023 update. Journal of Hypertension. 2023;41(6):1163-1199.
  4. 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.
  5. 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.
  6. Burnier M, et al. Drug adherence in hypertension: current status and future perspectives. Current Hypertension Reports. 2022;24(1):1-11.
  7. Musini VM, et al. Pharmacotherapy for hypertension in adults aged 60 or older. Cochrane Database of Systematic Reviews. 2019;6:CD011528.
  8. Weber MA, et al. Clinical practice guidelines for the management of hypertension in the community. Journal of Clinical Hypertension. 2014;16(1):14-26.
  9. Italian Society of Arterial Hypertension. ESH 2023 Guidelines for the Treatment of Arterial Hypertension. 2023.
  10. 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.