Hypertension Treatment Algorithm for Adults Without Comorbidities

Initial Classification and Risk Stratification

The American College of Cardiology recommends initiating treatment for adults with hypertension and no comorbidities based on blood pressure stage and cardiovascular risk, starting with lifestyle modifications alone for elevated BP or stage 1 hypertension with low cardiovascular risk, but adding pharmacotherapy immediately for stage 1 hypertension with 10-year ASCVD risk ≥10% or for stage 2 hypertension, targeting a blood pressure <130/80 mm Hg 1, 2
For elevated BP (120-129/<80 mm Hg), the American College of Cardiology suggests implementing lifestyle modifications only and reassessing BP in 3-6 months 1, 2
For stage 1 hypertension (130-139/80-89 mm Hg), the American College of Cardiology recommends calculating 10-year ASCVD risk to determine treatment approach, starting with lifestyle modifications alone if ASCVD risk <10%, and initiating both lifestyle modifications and pharmacotherapy if ASCVD risk ≥10% 1, 2
For stage 2 hypertension (≥140/90 mm Hg), the American College of Cardiology recommends immediately starting combination therapy with lifestyle modifications and two antihypertensive drugs from different classes, reassessing in 1 month 1, 3

The American College of Cardiology suggests choosing one agent from thiazide-type diuretic, ACE inhibitor or ARB, or calcium channel blocker as initial monotherapy for stage 1 hypertension with ASCVD risk ≥10% 4, 2
For initial dual therapy, the American College of Cardiology recommends starting with two agents, preferably as single-pill combination, including RAS blocker and dihydropyridine calcium channel blocker or thiazide-like diuretic 1, 5, 2
If BP remains above goal on dual therapy, the American College of Cardiology suggests switching to triple-drug single-pill combination, including ACE inhibitor or ARB, calcium channel blocker, and thiazide-like diuretic 4, 2

The American College of Cardiology recommends a blood pressure target of <130/80 mm Hg for adults <65 years 2
For adults ≥65 years, the American College of Cardiology suggests a systolic blood pressure target of <130 mm Hg, if tolerated and ambulatory, community-dwelling, non-institutionalized 3, 2

The American College of Cardiology recommends reassessing normal BP annually, elevated BP or stage 1 hypertension (low risk) in 3-6 months, and stage 1 hypertension (high risk) or stage 2 hypertension in 1 month 1
For very high BP (≥180/110), the American College of Cardiology suggests prompt evaluation and treatment initiation within 1 week 1

Before initiating treatment, the American College of Cardiology recommends confirming diagnosis with accurate office BP measurements, obtaining home BP monitoring or 24-hour ambulatory BP monitoring, assessing for medication non-adherence, and screening for secondary causes if resistant hypertension develops 2, 3, 6

The American College of Cardiology suggests utilizing team-based care, prescribing once-daily dosing, using single-pill combination products, implementing motivational interviewing and goal-setting strategies, and employing electronic health records, patient registries, and telehealth strategies to enhance treatment adherence 2, 6, 4, 5