The primary goal of treatment is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality. On the basis of current evidence from trials, blood pressures should be lowered to < 140/90 mm Hg at least, and, if tolerated, to levels < 130/80 mm Hg in diabetic patients.

Therapeutic Approach

The guidelines for initiating antihypertensive treatment are based on 2 criteria:
1. The total level of cardiovascular risk (Table 2), and
2. SBP and DBP levels (Table 1).
The total level of cardiovascular risk is the main indication for intervention, but lower or higher blood pressure values are also less or more stringent indicators for blood pressure-lowering intervention.
Recommendations for individuals with high normal blood pressure (SBP 130-139 or DBP 85-89 mm Hg on several occasions) include:
1. Assess other risk factors, TOD (particularly renal), diabetes, associated clinical conditions
2. Initiate lifestyle measures and correction of other risk factors or disease
3. Stratify absolute risk:

Very high/high: begin drug treatment

Moderate: monitor blood pressure frequently

Low: no blood pressure intervention
Recommendations for individuals with grades 1 and 2 hypertension (SBP 140-179 mm Hg or DBP 90-109 mm Hg on several occasions) include:
1. Assess other risk factors (TOD, diabetes, associated clinical conditions)
2. Initiate lifestyle measures and correction of other risk factors or disease
3. Stratify absolute risk

Very high/high: begin drug treatment promptly

Moderate: monitor BP and other risk factors for >/=3 months:

-- SBP >/= 140 or DBP >/= 90 mm Hg: begin drug treatment

-- SBP < 140 or DBP < 90 mm Hg: continue to monitor

Low: monitor BP and other risk factors for 3-12 months:

-- SBP >/= 140 or DBP >/= 90 mm Hg: consider drug treatment and elicit patient's preference

-- SBP < 140 or DBP < 90 mm Hg: continue to monitor
Recommendations for individuals with grade 3 hypertension (SBP >/= 180 or DBP >/= 110 mm Hg on repeated measurements within a few days):
1. Begin drug treatment immediately.
2. Assess other risk factors, TOD, diabetes, associated clinical conditions.
3. Add lifestyle measures and correction of other risk factors or diseases.

Lifestyle Changes

Lifestyle measures recommended include smoking cessation, weight reduction, reduction of excessive alcohol intake, physical exercise, reduction of salt intake, and increase in fruit and vegetable intake and decrease in saturated and total fat intake.

Choice of Antihypertensive Agents

The guidelines stress that the main benefits of antihypertensive therapy are due to the lowering of blood pressure per se. They list the standard major classes of antihypertensive agents suitable for the initiation and maintenance of therapy:
1. Diuretics
2. Beta-blockers
3. Calcium channel blockers (CCBs)
4. ACE inhibitors
5. Angiotensin-receptor blockers (ARBs).
Regarding a final class, alpha-adrenergic receptor blockers, the arm of the only trial testing an alpha-blocker (the doxazosin arm of ALLHAT) was terminated early, for an excess of cardiovascular events. Although the termination has been criticized,[9] evidence favoring alpha-blockers as antihypertensive therapy is more scanty than evidence of the benefits of other antihypertensive agents. Nevertheless, alpha-blockers should be considered as a therapeutic option, particularly for combination therapy.
In direct contrast to JNC 7, the European guidelines refrain from recommending specific classes of drugs as initial treatment; nevertheless, the guidelines recognize that there is evidence to support variable effects of specific drug classes on special subsets of patients. These include the elderly, pregnant women, diabetic patients; patients with concomitant cerebrovascular disease, coronary heart disease, or congestive heart failure; deranged renal function; or resistant hypertension. Specific indications are given for the major classes of antihypertensive drugs (Table 3).

Table 3. Indications for the Major Classes of Antihypertensive Drugs

ARBs, angiotensin receptor blockers; BPH, benign prostatic hyperplasia; CCBs, calcium channel blockers; CHF, congestive heart failure; ISH, isolated systolic hypertension; MI, myocardial infarction; LV, left ventricular
Finally, if, in the judgment of the physician, treatment can proceed with a single pharmaceutical agent, it is recommended that monotherapy be started gradually in most patients.

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