II. Protocol: Step 1 (Determine when and how to intervene)
- Review Hypertension Risk Stratification
- Determine Hypertension Reduction Goal
III. Protocol: Step 2
- Consider Hypertension Combination Therapy
- For Refractory Hypertensive Populations
- Combination therapy to start appears to be more effective than starting with monotherapy
- Choose agents first based on comorbidity and cohort
- Monotherapy (when not otherwise directed by comorbidity or cohort)
- Consider starting with combination tablet Lisinopril/Hctz 20/25 mg (Kaiser-Permanante)
- http://providers.kaiserpermanente.org/info_assets/cpp_cod/cod_adult_bp_clinician_guide.pdf
- Allows for dosing at 1/2 tablet (10/12.5 mg), 1 tablet, or 2 tablets (40/50 mg)
- Standard initial monotherapy choices
- Diuretics (e.g. Hydrochlorothiazide)
- If Diuretic is not first, it should be second
- Excellent adjunct to other antihypertensives
- Better outcomes than Lisinopril and Amlodipine
- Reduced risk of CVA, MI, CHF over other agents
- (2002) JAMA 288:2981-97 [PubMed]
- ACE Inhibitor or Angiotensin Receptor Blocker
- Preferred first-line agent in age under 60 years old
- Calcium Channel Blockers
- Diuretics (e.g. Hydrochlorothiazide)
- Compelling reason for other antihypertensive
- Agents to avoid for monotherapy
- Alpha blockers
- Hydralazine
- Minoxidil
- Beta Blocker
- Trend is to avoid Beta Blockers as first-line agents in uncomplicated Hypertension
- Reserve for patients with Coronary Artery Disease or Congestive Heart Failure
- Avoid if non-compliant (rebound Hypertension)
- Consider starting with combination tablet Lisinopril/Hctz 20/25 mg (Kaiser-Permanante)
IV. Protocol: Step 3
- Consider Hypertension Combination Therapy