SPRINT and other hypertension trials have used algorithm-based drug additions to reach the desired goals. In SPRINT, one or more antihypertensive drug classes with the strongest evidence to prevent cardiovascular disease outcomes were initiated and adjusted at the discretion of the investigators. The initial drug classes were thiazide-type diuretics (chlorthalidone was preferred unless advanced CKD was present, and then loop diuretics), calcium channel blockers (amlodipine preferred), ACE inhibitors (lisinopril was preferred), and ARBs (losartan or azilsartan medoxomil preferred).
The algorithms in this article may be considered for the treatment of hypertension. They are based on my experience, as well as on guidance from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.9
ALGORITHM 1is suitable for patients who initially need only 10/5 mm Hg lowering.10ALGORITHM 2A may be used for patients for whom you wish to lower BP by ≥20/10 mm Hg. I also recommend 2A for patients of Asian descent; that’s because ARBs are preferable to ACE inhibitors, which are associated with a high incidence of cough in this patient population. Either ALGORITHM 2A or 2B may be used for African-American patients with hypertension, as ACE inhibitors and ARBs alone are less effective for this group.
CORRESPONDENCE Steven Yarows, MD, FACP, FASH, IHA Chelsea Family and Internal Medicine, 128 Van Buren St, Chelsea, MI 48118; steven_yarows@ihacares.com.
