Henry R. Black, MD


December 19, 2013

In This Article

Recommendations 6-9

Recommendation 6

In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium-channel blocker, angiotensin-converting enzyme (ACE) inhibitor, or angiotensin receptor blocker. They specifically said "thiazide type," not "thiazide" as we did in JNC 7. This is a grade B recommendation, moderately supported by clinical trial evidence.

Recommendation 7

In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or calcium-channel blocker.

In the general black population, this was a moderate recommendation (grade B). For black patients with diabetes, it was a weak recommendation (grade C), although many experts think that this is a particularly important group to be aggressive with. They didn't address that.

Recommendation 8

In the population aged 18 years or older with chronic kidney disease, initial or add-on antihypertensive treatment should include an ACE inhibitor or angiotensin receptor blocker to improve kidney outcomes. This applies to all patients with chronic kidney disease with hypertension regardless of race or diabetes status. This is a moderate recommendation (grade B).

Recommendation 9

This is a little interesting, because it wasn't one of the original questions they discussed. It says the main objective with antihypertensive treatment is to attain and maintain goal blood pressure. If goal was not reached within 1 month of treatment, increase the dose of the initial drug or add a second drug from one of the classes recommended in recommendation 6 (thiazide-type diuretic, calcium-channel blocker, ACE inhibitors, or angiotensin receptor blockers).

The clinician should continue to assess blood pressure and adjust the treatment or regimen until goal blood pressure is reached. If goal blood pressure cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an angiotensin receptor blocker and an ACE inhibitor together in the same patient. If goal blood pressure cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal, antihypertensive drugs in other classes can be used.

And then you are advised to refer to a hypertensive specialist any patients in whom goals cannot be reached using the above strategy or for the management of complicated patients in whom additional clinical consultation is needed. This is also a grade E recommendation.

This wasn't one of the original questions. And it's important, because doctors are very interested in knowing, how often should I see the patient? When should I titrate?

They do provide an algorithm. It's very important in these situations to have what was hopefully a 1-page algorithm to be able to look at what's recommended. This is nicely summarized, although it would be very hard to fit on to a single slide or even two.


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