JNC 8 Hypertension Treatment Algorithm

Blood Pressure Classification (JNC 7 framework, still widely used)

Step 1 — Lifestyle Modifications (All Patients)

• Weight reduction (target BMI < 25 kg/m²) → ↓ SBP ~5–20 mmHg per 10 kg lost
• DASH diet (low saturated fat, low sodium) → ↓ SBP ~8–14 mmHg
• Sodium restriction (< 2.4 g/day) → ↓ SBP ~2–8 mmHg
• Regular aerobic exercise (30 min/day, most days) → ↓ SBP ~4–9 mmHg
• Alcohol limitation (≤ 2 drinks/day men, ≤ 1 drink/day women)
• Smoking cessation

Step 2 — Treatment Thresholds (JNC 8)

Step 3 — Initial Drug Selection

Non-African American Patients (including those with diabetes)

• Thiazide-type diuretic (e.g., chlorthalidone, HCTZ)
• Calcium Channel Blocker (CCB)
• ACE Inhibitor (ACEI)
• Angiotensin Receptor Blocker (ARB)

African American Patients (including those with diabetes)

• Thiazide-type diuretic or CCB
• (ACEI/ARB are less effective as monotherapy in this group)

Patients with CKD (all races)

• ACEI or ARB is mandatory (first-line or add-on), regardless of race or diabetes status
• Improves renal outcomes independent of BP lowering

Step 4 — Titration Algorithm

Start one drug (or two if BP is >20/10 mmHg above target)
          ↓
Reassess within 1 month
          ↓
Goal not reached?
    ├── Increase dose of initial drug
    └── OR add a second drug from a different class
          ↓
Still not at goal?
    └── Add third drug from remaining classes
          ↓
Goal still not reached?
    └── Refer to hypertension specialist
        Use other classes: aldosterone antagonists, α-blockers,
        central agents, direct vasodilators

• If BP is > 20/10 mmHg above target at presentation → start with two drugs simultaneously (combination pill preferred)
• Most patients (~75%) will need ≥ 2 drugs

Compelling Indications — Preferred Drug Classes

Important Combinations to Avoid

• ACEI + ARB (dual RAS blockade) — almost always contraindicated
• ARB + Renin inhibitor (e.g., aliskiren) — contraindicated
• Beta-blocker — not first-line in most patients with uncomplicated HTN (inferior stroke prevention vs. other classes)
• ACEI — avoid in pregnancy (teratogenic)

Resistant Hypertension

• Ensure medication adherence and correct technique
• Rule out secondary causes (renal artery stenosis, primary aldosteronism, pheochromocytoma, sleep apnea)
• Add spironolactone (aldosterone antagonist) 12.5–50 mg/day — has strong evidence
• Consider referral to hypertension specialist

• Chlorthalidone is preferred over HCTZ (longer-acting, more potent)
• CCBs are often under-used; peripheral edema can be mitigated by combining with a low-dose ACEI
• ACEI/ARB are safe in CKD with mild-moderate renal insufficiency; an increase in creatinine of up to 30–40% is acceptable if it stabilizes
• Monitor for hyperkalemia when using ACEI/ARB, especially in CKD

Hypertension Treatment Algorithm — Harrison's Principles of Internal Medicine (22nd Ed.)

BP Classification (ACC/AHA, used in Harrison's 22e)

Overall Treatment Algorithm (Fig. 288-3)

Step-by-Step Management by BP Category

Normal BP (SBP/DBP < 120/80 mmHg)

• Encourage healthy lifestyle habits
• Reassess after 12 months

Elevated BP (SBP 120–129, DBP < 80 mmHg)

• Active nonpharmacologic therapy only
• Reassess after 3–6 months

Stage 1 HTN (SBP 130–139 or DBP 80–89 mmHg)

• Reassess after 1 month

Stage 2 HTN (SBP ≥ 140 or DBP ≥ 90 mmHg)

• Always start antihypertensive drug therapy + nonpharmacologic therapy
• Most patients require ≥ 2 drugs — especially non-Hispanic Black adults and all with SBP ≥ 140 mmHg
• Reassess after 1 month

Nonpharmacologic Interventions (Table 288-2)

Greater BP reduction is expected when interventions are combined and in patients who already have hypertension. Nonpharmacologic interventions also enhance the effect of antihypertensive medications.

Drug Therapy — First-Step Classes (Fig. 288-4)

Beta-blockers are classified as "Other Drugs" — not first-line for uncomplicated HTN. In head-to-head RCTs, beta-blockers are inferior to the other four classes, especially for stroke prevention. Use only when there is a compelling indication (HF, post-MI, CAD, arrhythmia).

Evidence Hierarchy Among First-Step Classes

• Meta-analyses identify diuretics as "best in class" for first-step CVD prevention overall
• CCBs are better for stroke prevention but inferior for HF prevention vs. diuretics
• ACEI/ARBs are equivalent and interchangeable; do not use in combination

BP Treatment Targets

Resistant Hypertension

1. Exclude pseudo-resistance (inaccurate measurement)
2. Obtain out-of-office BP → exclude white coat HTN
3. Assess lifestyle adherence and medication nonadherence
4. Switch to long-acting diuretics (chlorthalidone or indapamide — replace HCTZ)
5. Convert multiple pills → single pill combination
6. Add Mineralocorticoid Receptor Antagonist (MRA):
   - Spironolactone (first choice, low cost)
   - Eplerenone or Finerenone (if gynecomastia/side effects)
7. If true resistant HTN with office SBP ≥ 160 mmHg:
   → Consider renal denervation (FDA-approved 2023)

Special Populations

Improving Hypertension Control

• Team-based care (nurses, pharmacists, community health workers with prescribing authority) — average ↓ SBP ~7 mmHg, up to 23 mmHg in optimized models
• Home BP monitoring (HBPM) to complement office measurements
• Single-pill combinations to improve adherence
• Electronic support systems and lifestyle counseling programs