Guidelines on the choice of agents and how best to step up treatment for various subgroups in hypertension (high blood pressure) have changed over time and differ between countries.

+ A Comparison of International Guidelines on Goal Blood Pressure and Initial Therapy for Adults With Hypertension (adapted from JNC 8 guidelines) Guideline Population Goal blood pressure (mmHg) Initial treatment options / 2025General<130/80BP ≥140/90: Two from different classes: thiazide diuretic, long-acting dihydropyridine CCB, and ACEi or ARB BP ≥130/80: One of: thiazide diuretic, long-acting dihydropyridine CCB, ACEi or ARB 2024General120–129/70–79BP >140/90: Two from different classes: preferably RAS-inhibitor (ACEi or ARB) with either thiazide diuretic/thiazide-like diuretic or dihydropyridine CCB 2023 Age <65

Age 65–79

Age ≥80<130/80

<140 SBP

<150 SBP BP <150/95: Lifestyle changes BP ≥150/95 or has CVD risk factors or failed lifestyle changes: Two from different classes: thiazide-type diuretic, ACEi/ARB, and/or CCB 2022General<140/90BP >140/90 and low-risk for CVD: Lifestyle changes

BP >140/90 and CVD risk factors or failed lifestyle changes: monotherapy with thiazide-type diuretic, ACEi/ARB, and/or CCB

BP >160/100: Two from different classes: thiazide-type diuretic, ACEi/ARB, and/or CCB 2021 General

High CVD risk, diabetes or CKD

Previous CVD<140/90

<130 SBP

<130 SBPBP ≥140/90 and low-risk for CVD: Two from different classes: thiazide-type diuretic, ACEi/ARB, and/or CCB

SBP ≥130 and CVD risk factors, diabetes or CKD: Two from different classes: thiazide-type diuretic, ACEi/ARB, and/or CCB

SBP ≥130 and previous CVD: Two from different classes: thiazide-type diuretic, ACEi/ARB, and/or CCB 2021 CKD with kidney transplant <120 SBP <130/80 CKD: ACEi/ARB Kidney transplant: ARB or CCB 2020 General Age <65

Age ≥65<140/90 (reduction by at least 20/10) <130/80

<140/90 BP >140/90 and low-risk for CVD: Lifestyle changes

BP >140/90 and CVD risk factors or failed lifestyle changes: monotherapy with thiazide-type diuretic, ACEi/ARB, and/or CCB

BP >160/100: Two from different classes: thiazide-type diuretic, ACEi/ARB, and/or CCB 2020General Age ≥60

Age ≥60 with diabetes<130/90 <150/90

<140/90Thiazide-type diuretic, ACEi/ARB, and/or CCB Black: avoid monotherapy with ACEi/ARB 2019 Age <80 Age ≥80 <140/90 <150/90 Age <55: ACEi/ARB

Age ≥55 or black: CCB 2018 Diabetes Diabetes with CVD risk <140/90 <130/80 ACEi/ARB, thiazide-like diuretic, and/or dihydropyridine CCB / 2018 Age <65 Age ≥65 <130/80 <140/80 Thiazide-type diuretic, ACEi/ARB, and/or CCB

CAD: add beta-blocker

Resistant hypertension: add spironolactone / 2017General<130/80BP > 130/80: Lifestyle changes and monotherapy with thiazide-type diuretic, ACEi/ARB, and/or CCB

BP >20/10 above target: Lifestyle changes and two from different classes: thiazide-type diuretic, ACEi/ARB, and/or CCB 2013 General age ≥60 General age <60

Diabetes

CKD <150/90 <140/90

<140/90

<140/90 Non-black: thiazide-type diuretic, ACEi/ARB, and/or CCB Black: thiazide-type diuretic, and/or CCB

Diabetes: thiazide-type diuretic, ACEi/ARB, and/or CCB

CKD: ACEi/ARB 2013 General age <80 General age ≥80

Diabetes

CKD <140/90 <150/90

<130/80

<140/90 General: thiazide-type diuretic, beta-blocker (age < 60), ACEi (non-black) or ARB Diabetes with additional risk : ACEi/ARB

Diabetes without additional risk : ACEi/ARB, thiazide, or DHPCCB

CKD: ACEi, or ARB 2010 Black, lower risk Target organ damage or CVD risk <135/85 <130/80 Diuretic or CCB

Abbreviations:

References