When a patient with essential hypertension has completed an initial course of first-line antihypertensive drug therapy and blood pressure remains above target at reassessment, the next clinical decision is how to escalate treatment safely and effectively.

Why the Previous Step Was Not Enough

First-line drug therapy — begun with a single agent or a two-drug combination drawn from thiazide-type diuretics, long-acting dihydropyridine calcium channel blockers, ACE inhibitors, and ARBs — did not achieve the goal of SBP <130 mm Hg and DBP <80 mm Hg by the one-month reassessment point. This failure to reach target is the trigger for stepping up to the next treatment level.

Next Step — Partial Overview

The evidence-based approach involves intensifying the regimen and optimising adherence by adding or adjusting agents from complementary first-line drug classes. The full stepwise protocol remains below.

Treatment Targets

SBP of at least <130 mm Hg (aiming for <120 mm Hg where achievable) and DBP <80 mm Hg, with reassessment at 3 to 6 months.

References

DOI: 10.1161/CIR.0000000000001356

Available RCT evidence supports using an RAS blocker with either a thiazide-type diuretic or a dihydropyridine CCB as initial therapy.
The stepped-care approach, defined by the initiation of antihypertensive drug therapy with a single agent followed by sequential titration of the dose and addition of other agents if needed, is a reasonable treatment strategy.
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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Essential Hypertension Not Controlled on Initial Antihypertensive Therapy