Elevated Blood Pressure Not Controlled on Initial Antihypertensive Therapy

This protocol applies when first-line antihypertensive treatment, added to lifestyle measures, has not brought blood pressure to the recommended targets after reassessment at monthly intervals.

Prior Treatment and Why It Fell Short

The previous step involved initiating antihypertensive medication using a first-line agent—a thiazide-type diuretic, a long-acting dihydropyridine calcium channel blocker, or an ACEi or ARB—alongside lifestyle intervention. For stage 2 presentations, two first-line agents of different classes may have been used.

The aim of that step was to achieve an average SBP <130 mm Hg and DBP <80 mm Hg, reassessed monthly until control was reached. When those targets remain unmet, this next-line protocol is indicated.

What This Protocol Involves

The strategy at this stage centres on the sequential addition of agents from complementary antihypertensive classes to build toward a multi-drug combination at maximally tolerated doses. The specific class choices, sequencing, and combination structure are detailed in the full protocol.

Target: SBP <130 mm Hg · DBP <80 mm Hg

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1161/CIR.0000000000001356

Antihypertensive drug therapy should start with a combination of an ACEi or ARB, a CCB, and a diuretic.
Replacing thiazide-type diuretics (eg, HCTZ or bendroflumethiazide) with thiazide-like diuretics (eg, chlorthalidone and indapamide) may offer additional BP reduction and cardiovascular protection among patients with previous MI or stroke.
In adults with confirmed hypertension who are at increased risk for CVD, an SBP goal of at least <130 mm Hg, with encouragement to achieve SBP <120 mm Hg, is recommended to reduce the risk of cardiovascular events and total mortality.

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