What are the VA/DoD guidelines for the management of hypertension (high blood pressure) in primary care settings?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

In 2014, the Department of Veteran’s Affairs/Department of Defense (VA/DoD) released an update of their 2004 guidelines for diagnosis and management of hypertension in primary care settings. Initiation of pharmacotherapy is recommended for all adults with either systolic BP ≥160 mm Hg or diastolic BP ≥90 mm Hg and for adults with a history of stroke, transient ischemic attack, or asymptomatic carotid artery disease and systolic BP ≥140 mm Hg. [129]

Treatment may also be considered for adults ages ≥60 years with systolic BP < 160 mm Hg. Combination therapy should be initiated for adults with systolic BP >20 mm Hg or diastolic BP >10 mm Hg above the target goal. Additional recommendations include the following [129] :

  • Thiazide-type diuretic as first-line therapy either as monotherapy or in combination with other drugs
  • Chlorthalidone or indapamide is preferred over hydrochlorothiazide
  • For patients who cannot tolerate thiazide-type diuretics, or as supplementary therapies for patients who do not reach their hypertensive goals with thiazide-type diuretics, or for those starting on combination therapy: ACEIs or ARBs (but not both together); long-acting dihydropyridine calcium channel blockers
  • For patients with chronic kidney disease, ACEIs or ARBs for improving kidney outcomes
  • In African Americans, recommend against ACEIs or ARBs as monotherapy
  • In African Americans with stage 1-3 chronic kidney disease, the combination of a thiazide-type diuretic (for cardiovascular protection) with either an ACEI or an ARB (for renal protection)

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