1. Set appropriate
blood pressure goals (for most patients, SBP < 140 mm Hg and
DBP < 90 mm Hg).
2. Institute
lifestyle modifications, including weight loss and salt restriction.
3. If hypertension
persists, institute drug treatment. Selection includes the following
factors:
Starting with
a single agent.
- Starting
dose should be lowered in elderly patients; approximately one
half the dose in younger patients.
- Long-acting
formulations are preferred for better compliance.
- Low-dose
combination agents may be helpful in minimizing side effects.
- Titrate
upward and/or add a second agent if goal is not reached after
1 to 2 months (for example, patients in the SHEP trial were
seen every month until goal blood pressures were achieved).
4. Specifically
with regard to ISH in the elderly, JNC VI recommends first-line
therapy selections of long-acting calcium channel blockers, thiazide
diuretics, or beta blockers in combination with thiazide diuretics.
5. Other appropriate
starting regimens could include beta blockers for patients with
tachycardia or previous myocardial infarction, angiotensin-converting
enzyme inhibitors in patients with proteinuria or heart failure,
or long-acting oral nitrates in patients with angina.
6. We do not
recommend alpha adrenergic blockers as first-line agents at this
time.
7. In all
cases, decisions and regimens must be instituted and tailored
in accord with a patient's other comorbid conditions and responses
to medication.