Department of Veterans Affairs

Department of Defense

VA/DoD Clinical Practice Guideline

for 

The Diagnosis and management of Hypertension 

in Primary Care Setting

Guideline Summary

Prepared by:

The Hypertension

Working Group

With support from:

The Office of Quality, Safety and Value, VA, Washington, DC

and

Quality Performance Assurance Directorate, United States Army MEDCOM

Full guideline available at:

http://www.healthquality.va.gov or https://www.qmo.amedd.army.mil

QUALIFYING STATEMENTS

The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based upon the best 

information available at the time of publication. They are designed to provide information and assist decision-making. 

They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted 

as prescribing an exclusive course of management.

Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual 

patients, available resources, and limitations unique to an institution or type of practice. Every health care professional 

making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any 

particular clinical situation. 

Version 3.0 – 2014
2 | Guideline Summary – 2014

DISCLAIMER

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by 

a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options 

and health outcomes while rating both the quality of the evidence and the strength of the recommendations.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing 

and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional 

information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed 

Care Support Contractor.

TABLE OF CONTENTS

SUMMARY........................................................................................................................................................................ 3

ALGORITHM...................................................................................................................................................................... 6

RECOMMENDATIONS....................................................................................................................................................... 8

PHARMACOLOGICAL AGENTS ......................................................................................................................................14

REFERENCES ...................................................................................................................................................................16
 Management of Hypertension | BACKGROUND | 3

SUMMARY

In the United States (US), about 77.9 million adults (one out of every three) have hypertension. Of those only 81.5% are 

aware of their condition, 74.9% are undergoing treatment, and just over half (52.5%) have their hypertension controlled. 

[1] Uncontrolled hypertension has been shown to be higher in older Americans, non-Hispanic blacks and individuals 

with certain co-morbid conditions, including diabetes and chronic kidney disease (CKD). [2]

In a 2008 study, it was found that 13% of active duty Service Members had hypertension, the majority of which were 

<40 years of age. [3] It was reported that, as in the civilian population, increased age, increased body mass index (BMI), 

male sex, black race/ethnicity, and senior rank were all independently associated with hypertension. Over 37% of 

Veterans have hypertension, making it the most common chronic medical condition among Veterans. [4] The control 

of hypertension, however, has significantly improved among Veterans. While only 45.7% of Veterans had their blood 

pressure controlled in 2000, by 2010, the rate had improved to 76.3%. [5]

Hypertension is clinically defined as a systolic blood pressure (SBP) ≥140 mmHg or a diastolic blood pressure (DBP) of 

≥90 mmHg. Prehypertension is classified as SBP 120-139 or DBP 80-89. Hypertension is usually asymptomatic; therefore, 

routine screening is important in order to diagnosis the condition. Also, because patients will mostly not feel sick, the 

asymptomatic nature of hypertension can lead to challenges with adherence to treatment.

Complications of hypertension include damage to the large arteries (macrovascular complications) that can lead to 

stroke, myocardial infarction (MI), or peripheral arterial diseases, as well as damage to the smaller arteries (microvascular 

complications) that can lead to CKD or retinopathy. In addition to these arterial complications, hypertension by itself can 

lead to left ventricular hypertrophy (LVH) and congestive heart failure (CHF), another frequent cause of death in the US.

The Department of Veterans Affairs (VA) and the Department of Defense (DoD) Clinical Practice Guideline (CPG) for 

the Diagnosis and Management of Hypertension in the Primary Care Setting is intended to assist healthcare providers 

in all aspects of outpatient care for patients with hypertension. The system-wide goal of evidence-based guidelines 

is to improve the patient’s health and wellbeing. The overall expected outcome of successful implementation of this 

guideline is to:

• Formulate an efficient and effective assessment of the patient’s condition

• Optimize the use of therapy to reduce symptoms and enhance functionality

• Minimize preventable complications and morbidity

• Emphasize the use of personalized, proactive, patient-driven care

This CPG addresses various management strategies for patients with hypertension (HTN). This includes assessing the 

benefits and harms associated with antihypertensive pharmacologic therapies as well as the blood pressure thresholds 

to initiate therapy and appropriate blood pressure targets. In addition to primary care provider pharmacological 

management strategies, the CPG discusses the impact of non- pharmacologic therapies (e.g., weight reduction, sodium 

reduction, physical activity) on improving hypertension management. The CPG also reviews what measurement 

techniques are the best indicators to initiate hypertension therapy.
4 | Guideline Summary – 2014

STRENGTH OF RECOMMENDATIONS

This CPG uses the GRADE methodology to assess the quality of the evidence base and assign a grade for the strength 

for each recommendation. The GRADE system uses the following four domains to assess the strength of each 

recommendation: [6]

• Balance of desirable and undesirable outcomes

• Confidence in the quality of the evidence

• Values and preferences

• Other implications, as appropriate, e.g.,:

- Resource Use

- Equity

- Acceptability

- Feasibility

- Subgroup considerations

The framework below was used by the VA/DoD HTN Work Group to guide discussions on each domain.

Table 1. Evidence to Recommendation Framework

Table 1. Evidence to Recommendation Framework

Decision Domain Judgment

Balance of desirable and undesirable outcomes

Given the best estimate of typical values and preferences, 

are you confident that the benefits outweigh the harms 

and burden or vice versa?

Are the desirable anticipated effects large? Are the 

undesirable anticipated effects small?

Are the desirable effects large relative to undesirable 

effects?

Benefits outweigh harms/burden 

Benefits slightly outweigh harms/burden 

Benefits and harms/burden are balanced 

Harms/burden slightly outweigh benefits 

Harms/burden outweigh benefits

Confidence in the quality of the evidence

Is there high or moderate quality evidence that answers 

this question?

What is the overall certainty of this evidence?

High 

Moderate 

Low

Very low

Values and preferences

Are you confident about the typical values and 

preferences and are they similar across the target 

population?

What are the patient’s values and preferences?

Are the assumed or identified relative values similar 

across the target population?

Similar values 

Some variation 

Large variation

Other implications (e.g., resource use, equity, acceptability, feasibility, subgroup considerations):

Are the resources worth the expected net benefit from 

the recommendation?

What are the costs per resource unit? Is this intervention 

generally available?

Is this intervention and its effects worth withdrawing or 

not allocating resources from other interventions?

Is there lots of variability in resource requirements across 

settings?

Various considerations
 Management of Hypertension | BACKGROUND | 5

The strength of a recommendation is defined as the extent to which one can be confident that the desirable effects 

of an intervention outweigh its undesirable effects, and is based on the framework above, which combines the four 

domains. [6]

The GRADE of a recommendation is based on the following elements:

• Four decision domains used to determine the strength and direction (described above)

• Relative strength (Strong or Weak)

• Direction (For or Against)

The relative strength of the recommendation is based on a binary scale, “Strong” or “Weak.” A strong recommendation 

indicates that the Work Group is highly confident that desirable outcomes outweigh undesirable outcomes. If the 

Work Group is less confident of the balance between desirable and undesirable outcomes, they present a weak 

recommendation.

Similarly, a recommendation for a therapy or preventive measure indicates that the desirable consequences outweigh 

the undesirable consequences. A recommendation against a therapy or preventive measure indicates that the 

undesirable consequences outweigh the desirable consequences.

Using these elements, the grade of each recommendation is presented as part of a continuum:

• Strong For (or “We recommend offering this option ...”)

• Weak For (or “We suggest offering this option ...”)

• Weak Against (or “We suggest not offering this option ...”)

• Strong Against (or “We recommend against offering this option ...”)
6 | Guideline Summary – 2014

Algorithm A Screening and Diagnosis

2

3

7

4 5

10

9

11

13

12

6

8

1

14

15

16

17

18

19

20

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

Does patient have a 

history of hypertension?

Does patient have an 

acute injury or illness?

Are both SBP and 

DBP <140/90 mmHg?

Is secondary cause 

suspected?

Is SBP ≥ 120 mmHg or

DBP ≥ 80 mmHg?

(see sidebar A)

Consider confirming diagnosis

(see sidebar B)

Evaluate, as indicated;

Consider referral

Return after acute episode resolved 

(typically within 4 weeks)

Go to box 21

(Module B)

Adult in health care system

Normal Blood Pressure Hypertension Prehypertension

Initiate treatment

Go to Algorithm B

Screen blood pressure annually

Address other CV RFs;

In patient with known or suspected 

target organ damage, consider 

possibility of masked hypertension

Obtain blood pressure (reliable, 

standardized, measurement)

Obtain second blood pressure 

measurement (current visit); 

Is SBP ≥ 120 mmHg or

 DBP ≥ 80 mmHg?

Initiate lifestyle modification

(e.g., diet, exercise, weight loss, 

alcohol moderation)

Obtain history, physical, and lab tests

(see table C)

Assess target organ damage and/or 

associated clinical conditions

Follow up per lifestyle modification 

program;

Screen BP at least annually;

Address other CV RFs

Sidebar C: Recommended Lab Tests

• Urinalysis; consider an albumin 

to creatinine ratio test if urinalysis 

is positive for protein

• Basic metabolic panel

• Non-fasting lipid profile

• 12-lead electrocardiogram

• Hematocrit and calcium (optional)

Sidebar B: Confirm Diagnosis

Confirm clinical BP within 1-4 weeks.

- If the follow-up BP value is ≥ 140 mmHg SBP

 or ≥ 90 mmHg DBP, make diagnosis without further testing.

- If the follow-up BP value is within prehypertensive range or 

provider/patients is uncertain about diagnosis, 

consider performing HBPM or 24-hour ABPM.

Diagnose hypertension if:

 - HBPM: SBP ≥135 or DBP ≥ 85

 - 24-hour ABPM: SBP ≥ 130 or DBP ≥80

If HBP or ABP is less than the values above, consider diagnosing as 

prehypertension or white coat hypertension depending on blood 

pressure reading (see sidebar A)

Sidebar A: Classification

 SBP (mmHg) DBP (mmHg)

Normal < 120 and < 80

Prehypertension* 120-139 and/or 80-89

Hypertension ≥140 or ≥ 90

* But not ≥ 140 mmHg SBP 

or ≥ 90 mmHg DBP.

ABPM= Ambulatory Blood Pressure Monitoring; HBPM =Home Blood Pressure Monitoring; ACEI=Angiotensin-converting Enzyme Inhibitor; ARB=Angiotensin II Receptor Blocker; 

CKD=Chronic Kidney Disease; DBP=Diastolic Blood Pressure ; DHP CCB=Dihydropyridine Calcium Channel Blocker; TOD=Target Organ Damage; SBP=Systolic Blood Pressure; 
 Management of Hypertension | ALGORITHMS | 7

Algorithm B Management of Hypertension Acronym List

22

23

26

24

27

28

29

32

36

34

35

36

37

38

39

38

33

30

31

21

No

No

No

25

Y

No

Yes

Yes

Y

Yes

Yes

No

No

No

Y

Yes

Determine blood pressure goal

(see sidebar D)

Implement shared decision 

making to assess patient values 

and preferences

Follow up periodically; 

Reassess preferences

Does patient want to 

engage in treatment for 

hypertension?

Is the patient SBP ≥ 160 

mmHg or DBP ≥ 90 mmHg or 

does the patient have a history of 

cerebrovascular disease?

Does the patient want to 

engage in pharmacotherapy

Is the patient’s baseline 

SBP > 20 mmHg or DBP > 10 

mmHg above BP goal?

Does the patient have 

comorbid conditions (i.e., CKD, 

diabetes, obesity,etc.,)? 

Is patient’s blood pressure at 

or below goal?

Is patient’s blood pressure at 

or below goal?

Follow up (at least monthly) and 

reassess treatment until blood 

pressure is at goal or as dictated 

by comorbid conditions and other 

patient preferences

Optimize treatment

(see sidebar f)

Initiate monotherapy 

and offer LSM 

intervention

(see sidebar E)

Initiate combination 

therapy and offer 

LSM intervention

(see sidebar E)

Initiate LSM intervention (diet, 

physical activity, weight loss, etc.,)

Follow up regularly (e.g., 

monthly) until:

• Blood pressure is at goal

• Treatment regimen is optimized

• Comorbid conditions and other 

patient preferences direct otherwise Engage relevant clinical practice 

guidelines, when available (i.e., CKD, 

Lipids, Diabetes, Obesity, Tobacco 

Cessation, etc.,)

Patient with hypertension

Patient refuses treatment

Follow up at frequency dictated 

by comorbid diseases, but at least 

annually (to include lab monitoring, if 

indicated)

Sidebar D: Goals for Blood Pressure

Without diabetes <150/90 mmHg

With diabetes <150/85 mmHg

 *<140/85 mmHg

* Suggested for patients with diabetes 

who tolerate the antihypertensive 

medications necessary to reach this goal.

Sidebar E: Initiate drug Therapy

General population (including patients with coronary diseas, prior MI, or diabetes)

1st Line Thiazide type diuretics

2nd Line ACEIs, ARBs, or long acting DHP CCBs

Additional drug classes may be added as needed to reach BP goal. ((See Table 3)

Specific Populations:

For patients with CKD, recommend ACEIs or ARBs as 1st line therapy

For African American patients, recommend not using ACEIs or ARBs as monotherapy.

For African American patients with CKD, suggest combining a thiazide type diuretics with an ACEI or ARB.

Sidebar F: Optimize Treatment

• Optimize treatment (see Table 3)

• Titrate initial drug

• Add another agent from a different class

• Assess adherence

• Reevaluate diagnosis (resistant HTN)

• Consider evaluation for interfering substances or 

contributing secondary causes of hypertension

• Consider specialty consultation for patients with 

resistant hypertension
8 | Guideline Summary – 2014

Recommendations

A Screening

1. We recommend screening adults for elevated blood pressure occur periodically, preferably annually. 

[Strong For] 

(Modified from 2004 VA/DoD HTN CPG without an updated systematic review of the evidence.)

2. We suggest that screening occur at the time of routine preventive care or routine health assessment. 

[Weak For]

(Modified from 2004 VA/DoD HTN CPG without an updated systematic review of the evidence.)

B. Diagnosis

3. We recommend the diagnosis of hypertension be determined based on at least two blood pressure 

readings on two separate patient visits [Strong For]

(Modified from 2004 VA/DoD HTN CPG without an updated systematic review of the evidence.)

C. Measurement Techniques

4. We recommend that blood pressure be measured with a technique recommended for 

the measurement of blood pressure in adults using a properly calibrated and validated 

sphygmomanometer. [Strong For]

(Modified from the 2004 CPG without an updated systematic review of the evidence.)

5. For patients whose diagnosis of hypertension remains uncertain, we recommend offering home blood 

pressure monitoring to confirm diagnosis prior to beginning pharmacologic treatment. (Two to three 

times a day for seven consecutive days, disregard the first day and take the average of measurements.) 

[Strong For]

6. For patients whose diagnosis of hypertension remains uncertain, we suggest offering 24 hour 

ambulatory blood pressure monitoring as an alternative to home blood pressure monitoring to 

confirm diagnosis prior to beginning pharmacologic treatment. [Weak For]

D. Adherence to Therapy

7. We suggest offering a multi-modal approach to adherence interventions, which could include telemonitoring, multi-disciplinary group medical appointments, (e.g., shared medical appointments), case 

management (by pharmacists, nurses, social workers), patient and provider education, behavioral 

therapy, etc.. [Weak For ]
 Management of Hypertension | RECOMMENDATIONS | 9

E. Lifestyle Modification

8. We recommend offering lifestyle modification interventions for patients with prehypertension or 

hypertension based on patient indications and preferences as well as assessment of available local 

resources. [Strong For ]

(Modified from 2004 VA/DoD HTN CPG)

Weight Reduction

9. We recommend discussing healthy weight range and advising overweight or obese hypertensive 

patients to reduce their body mass index to below 25. [Strong For]

(Modified from 2004 VA/DoD HTN CPG)

10. If a normal body mass index (<25) cannot be achieved, we suggest advising patients that a weight 

reduction of at least 10 pounds can achieve a decrease in blood pressure. [Weak For]

Exercise/Physical Activity

11. We recommend a target for aerobic exercise of 30 to 45 minutes per session, at least four times per 

week. [Strong For]

(Modified from 2004 VA/DoD HTN CPG)

12. We suggest the use of a self-monitoring device (e.g., pedometer, mobile apps, etc.) to increase 

adherence to physical activity. [Weak For]

Mind-body/Alternative Therapies

13. For patients interested in complementary and alternative medicine, we suggest considering mindbody therapies such as transcendental meditation or yoga. [Weak For]

14. We suggest not offering Tai Chi for the treatment of hypertension as there is a moderate body of 

evidence that shows this intervention does not reduce blood pressure. [Weak Against]

Dietary Modification 

15. We recommend a dietician-led Dietary Approaches to Stop Hypertension (DASH) Diet for the 

treatment and/or prevention of hypertension for patients with hypertension and/or interested 

patients with prehypertension and other cardiovascular risk factors. [Strong For]

(Modified from 2004 VA/DoD HTN CPG)

16. In patients with additional cardiovascular risk factors, such as dyslipidemia, we suggest considering a 

dietician-led Mediterranean Diet as an alternative to the DASH Diet. [Weak For]

17. We recommend against the use of soy protein supplements for the treatment of hypertension. 

[Strong Against]

Sodium Reduction

18. In patients with hypertension or prehypertension, we recommend that sodium intake be limited to no 

more than 2300 mg/day (100 mmol/day), with referral to a dietician or other support as appropriate. 

[Strong For]

(Modified from 2004 VA/DoD HTN CPG). 

Alcohol Reduction

19. We recommend advising hypertensive and prehypertensive patients to limit alcohol intake to no more 

than 1 oz per day for men or 0.5 oz of alcohol per day for women. (This is approximately 2 drinks/day 

in men and 1 drink/day in women, where a drink is 1.5 oz 80-proof liquor, 12 oz beer, or 5 oz wine [all 

14g]). [Strong For]

(Modified from 2004 VA/DoD HTN CPG).
10 | Guideline Summary – 2014

Pharmacological Therapy

H. Initiation of Pharmacotherapy

20. We recommend offering pharmacologic treatment for hypertensive patients 60 years and older with a 

systolic blood pressure ≥ 160mmHg. [Strong For]

21. We suggest considering pharmacologic treatment using a shared decision- making model for 

hypertensive patients 60 years and older with systolic blood pressure <160mmHg. [Weak For]

22. We suggest offering pharmacologic treatment to patients with a history of cerebrovascular disease 

(stroke, transient ischemic attack, or asymptomatic carotid artery disease) and a systolic blood pressure 

≥140mmHg. [Weak For]

23. We suggest pharmacologic treatment for hypertensive patients younger than 60 with a systolic blood 

pressure ≥160mmHg, regardless of diastolic blood pressure. [Weak For]

24. We recommend offering pharmacologic treatment for patients 30 years and older with a diastolic blood 

pressure ≥90mmHg. [Strong For]

25. We suggest offering pharmacologic treatment for patients age 18 to 29 with a diastolic blood pressure 

≥90mmHg. [Weak For]

G. Blood Pressure Goals

26. For patients 60 years and over, we recommend treating to a systolic blood pressure goal of 

<150mmHg. [Strong For]

27. For patients below 60 years of age, we suggest treating to a systolic blood pressure goal of 

<150mmHg. [Weak For]

28. We recommend treating to a diastolic blood pressure goal <90mmHg in patients 30 years and older. 

[Strong For]

29. We suggest treating to a diastolic blood pressure goal <90mmHg in patients age 18 to 29. [Weak For]

30. For patients with diabetes (all age groups), we recommend treating to a systolic blood pressure goal of 

<150mmHg. [Strong For]

31. For patients with diabetes (all age groups) who tolerate antihypertensive drugs, we suggest treating to 

a systolic blood pressure goal of <140mmHg. [Weak For]

32. For patients with diabetes, we recommend treating to a diastolic blood pressure goal <85mmHg. 

[Strong For]

H. Hypertension Control and Follow-up

33. We suggest that patients be seen within one month of initiation of lifestyle or pharmacological therapy 

to determine adequacy of hypertension control, degree of patient adherence, and presence of adverse 

effects. [Weak For]

(Modified from 2004 VA/DoD HTN CPG without an updated systematic review of the evidence.)

34. Once the patient’s blood pressure is controlled, we suggest follow-up at least annually or more 

frequently as indicated, depending on patient preference. [Weak For]

 (Modified from 2004 VA/DoD HTN CPG without an updated systematic review of the evidence.)
 Management of Hypertension | RECOMMENDATIONS | 11

I Monotherapy or Combination Therapy

35. We suggest taking into consideration the patient’s baseline blood pressure and presence of 

comorbidities, when deciding on either monotherapy or combination therapy (two drugs) when 

initiating drug therapy. [Weak For]

(Modified from 2004 VA/DoD HTN CPG without an updated systematic review of the evidence.)

36. We suggest initiating combination therapy for patients with a baseline systolic blood pressure of 

>20mmHg or diastolic blood pressure of >10mmHg above the patient’s goal. [Weak For]

(Modified from 2004 VA/DoD HTN CPG without an updated systematic review of the evidence.)

J. First Line Therapy

37. We recommend the use of thiazide-type diuretics for the treatment of hypertension. [Strong For]

38. We suggest the use of thiazide-type diuretics at recommended treatment doses as first line therapy for 

drug treatment of hypertension either as monotherapy or in combination with other agents. [Weak 

For] 

(Modified from 2004 VA/DoD HTN CPG)

39. To initiate treatment of hypertension with a thiazide-type diuretic, we suggest the use of 

chlorthalidone or indapamide over hydrochlorothiazide. [Weak For]

40. We do not suggest switching from hydrochlorothiazide to chlorthalidone or indapamide if the patient 

is adequately controlled on and tolerating hydrochlorothiazide. [Weak Against]

41. We suggest considering a switch from hydrochlorothiazide to chlorthalidone for patients whose 

hypertension is inadequately controlled on 50mg/day of hydrochlorothiazide. [Weak For]

42. We recommend a dosage of 12.5-25mg/day of chlorthalidone, 25-50mg/day of hydrochlorothiazide, or 

a dosage of 2.5mg/day immediate-release or 1.5- 2.5mg/day sustained-release (not currently available 

in the US) of indapamide. [Strong For]

K. Alternative or Supplementary Therapies

43. We recommend using the following as alternative therapies for patients who cannot tolerate thiazidetype diuretics, as supplementary therapies for patients who do not reach their hypertensive goals, or 

for those starting on combination therapy: [Strong For]

a. Angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers (but not 

together)

b. Long-acting dihydropyridine calcium channel blockers. 

(Modified from 2004 VA/DoD HTN CPG)

44. We recommend against the use of more than one of the following three drug classes together in the 

same patient: angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, or direct 

renin inhibitors. [Strong Against]

45. We recommend additional therapy in refractory hypertension (for those who do not tolerate or are 

not adequately controlled with triple therapy [i.e., thiazide- type diuretics, ACEI or ARB, and CCBs] 

described in Recommendation 43) or as supplementary therapy in some clinical indications. Drug 

classes for consideration can include (not in priority order): [Strong For]

a. Aldosterone/mineralocorticoid receptor antagonists (e.g., spironolactone, eplerenone)

b.Other potassium-sparing diuretic (i.e., amiloride)
12 | Guideline Summary – 2014

c. Alpha adrenergic blockers

d. Beta adrenergic blockers

e. Non-dihydropyridine calcium channel blockers

f. Combined alpha-beta adrenergic blockers

g. Peripherally acting antiadrenergic agents (reserpine, pending availability)

h.Direct acting vasodilators (e.g., hydralazine, minoxidil)

i. Centrally acting antiadrenergic drugs (e.g., clonidine, methyldopa).

46. We recommend against the use of alpha-adrenergic blockers as monotherapy, but this class of agents 

may be used as supplemental therapy or if warranted by comorbid conditions (e.g., symptomatic 

prostatic hypertrophy). [Strong Against]

(Modified from 2004 VA/DoD HTN CPG)

L. Specific Populations

47. In patients with hypertension and chronic kidney disease (reduced kidney function with albuminuria), 

we recommend treatment with an angiotensin- converting-enzyme inhibitor, or angiotensin II 

receptor blocker for improving kidney outcomes. [Strong For]

 (Modified from 2004 VA/DoD HTN CPG)

48. In African American patients with hypertension, we recommend against using an angiotensinconverting-enzyme inhibitor or angiotensin II receptor blocker as monotherapy. [Strong Against] 

49. In African American patients with hypertension and stage 1-3 chronic kidney disease, we suggest a 

combination of a thiazide-type diuretic (for cardiovascular protection) with either an angiotensinconverting-enzyme inhibitor or angiotensin II receptor blocker (for renal protection). [Weak For]
 Management of Hypertension | RECOMMENDATIONS | 13

Table 2. Blood Pressure Thresholds to Initiate Pharmacologic Treatment and Treatment Goals by 

Patient Category and Age

Category of Patient

Patient 

Age

Blood 

Pressure 

(mmHg)a General Population Diabetic Population History of cerebrovascular 

disease

18-29

years

Initiate

SBP >160 (Suggested) >160 (Suggested)b >140 (Suggested)

DBP >90 (Suggested) >90 (Suggested)b >90 (Suggested)b

Goals

SBP <150 (Suggested)

<150 (Recommended)

<140 (Suggested for those who 

tolerate medication)

<150 (Suggested)b

DBP <90 (Suggested) <85 (Recommended) <90 (Suggested)b

30-59

years

Initiate

SBP >160 (Suggested) >160 (Suggested)b >140 (Suggested)

DBP >90 (Recommended) >90 (Recommended)b >90 (Recommended)b

Goals

SBP <150 (Suggested)

<150 (Recommended)

<140 (Suggested for those who 

tolerate medication)

<150 (Suggested)b

DBP <90 (Recommended) <85 (Recommended) <90 (Recommended)b

>60

years

Initiate

SBP

>160 (Recommended)

160 > SBP > 140

(Suggested; using shared 

decision making)

>160 (Recommended) b

160 > SBP > 140 

(Suggested; using shared 

decision making) b

>140 (Suggested)

DBP >90 (Recommended) >90 (Recommended) b >90 (Recommended)b

Goals

SBP <150 (Recommended)

<150 (Recommended)

<140 (Suggested for those who 

tolerate medication)

<150 (Recommended)b

DBP <90 (Recommended) <85 (Recommended) <90 (Recommended)b

a Initiate pharmacologic treatment at SBP OR DBP threshold; once pharmacologic treatment is initiated, treat to SBP AND DBP goals.

b Evidence was not reviewed which indicated the blood pressure value should be different from the general population.
14 | Guideline Summary – 2014

Table 3. Recommended Dosage for Selected Hypertension Drug Therapy

Drug a Usual Dose Range Comments h

Thiazide-type Diuretics

Chlorthalidoneb 12.5-25 mg daily • May cause hyperuricemia/gout. 

• Monitor K+ levels.

• May cause photosensitivity (rare). 

HCTZb 12.5-50 mg daily f

Indapamide IR: 2.5 mg daily

SR: 1.25 – 2.5 mg daily

• SR not currently available in the US. 

• For complete drug information, review the manufacturer’s prescribing 

information.

Angiotensin-Converting Enzyme Inhibitors

Benazepril 10-40 mg/day (daily or divided bid) • When pregnancy is detected, discontinue as soon as possible, due to potential for 

fetal and neonatal morbidity and death. Patients of childbearing potential should 

also be educated about the risks.

• Do not use if history of angioedema.

• Avoid concomitant use of ACEI with ARB or direct renin inhibitor due to increased 

risk of hypotension, syncope, increased K+, and changes in renal function (See 

recommendation #44).

• Monitor K+ and kidney function; use caution if combined with, K+ sparing 

diuretic, or K+ supplement.

• Consider interruption or discontinuation in patients who develop clinically 

significant decline in kidney function after initiation of therapy, until further 

work-up, as indicated (e.g., renal artery stenosis).

Enalapril 5-40 mg/day (daily or divided bid)

Fosinopril 10-40 mg daily

Lisinoprilb 10-40 mg daily

Ramipril b,c 2.5-20 mg/day (daily or divided bid)

(10 mg daily for CV risk prevention)

Angiotensin II Receptor Blockers

Azilsartanc 40-80 mg daily • When pregnancy is detected, discontinue as soon as possible. Drugs that act 

directly on the renin angiotensin system can cause injury and death to the 

developing fetus. Patients of childbearing potential should also be educated 

about the risks.

• Avoid concomitant use of ACEI with angiotensin II receptor blocker or direct renin 

inhibitor due to increased risk of hypotension, syncope, increased K+, and changes 

in renal function (See recommendation #44). 

• Monitor K+ and kidney function; use caution if combined with, K+ sparing diuretic, 

or K+ supplement.

• Consider interruption or discontinuation in patients who develop clinically 

significant decline in kidney function after initiation of therapy, until further workup, as indicated (e.g., renal artery stenosis).

Candesartanc 8-32 mg daily

Eprosartanc 400-800 mg/daily (daily or divided bid)

Irbesartanc 150-300 mg daily

Losartanb 25-100 mg/day (daily or divided bid)

Olmesartanc 20-40 mg daily

Telmisartanc 20-80 mg daily

Valsartanb,d 80-320 mg daily

Long-Acting Dihydropyridine Calcium Channel Blockers

Amlodipineb 2.5-10 mg daily • Monitor adverse effects (DHP CCBs may cause ankle edema, dizziness, flushing, 

headache). 

• Use with caution in patients with hepatic or kidney dysfunction.

Felodipine 2.5-10 mg daily

Nifedipine SRb 30-120 mg daily

Aldosterone/mineralocorticoid Receptor Antagonists

Eplerenonec 50-100 mg/day (daily or divided bid) • Avoid use if hyperkalemia or severe kidney dysfunction.

• Monitor K+ and kidney function; consider risk vs. benefit if combined with ACEI, 

ARB, K+ sparing diuretic, or K+ supplement.

• Higher risk of gynecomastia with spironolactone than eplerenone.

Spironolactoneb 25-50 mg/daily
 Management of Hypertension | PHARMACOLOGICAL AGENTS | 15

Drug a Usual Dose Range Comments h

Other Potassium-Sparing Diuretics

Amiloridec 5-10 mg daily • Avoid use if hyperkalemia or severe kidney dysfunction.

• Helpful in reducing hypokalemia caused by thiazide diuretics.

Alpha-Adrenergic Blockers

Doxazosin 1-16 mg daily • Initiate at low doses (1 mg)

• Administer 1st dose at bedtime to avoid syncope. 

• Avoid as monotherapy (See recommendation #46 in the CPG).

Prazosin 2-20 mg/day (Divided bid or tid)

Terazosinb 1-20 mg daily

Beta-Adrenergic Blockers

Noncardioselective:

• Discontinue with slow taper over one week.

• Avoid combination with non-DHP CCB due to increased risk of bradycardia.

• As doses increase, cardioselectivity decreases.

• Beta-blockers should be used cautiously in asthma

Propranolol IR: 80-160 mg/day (divided bid) 

SR: 80-160 mg daily

Cardioselective:

Atenololb 25-100 mg daily (adjust dose in CKD) 

Metoprolol tartrateb IR: 50-300 mg/day (daily or divided bid) 

Metoprolol succinate (XL) b,d SR: 25-200 mg/day

Long-Acting Non-Dihydropyridine Calcium Channel Blockers

Verapamil SRb 120-480 mg divided daily-bid • Verapamil may cause constipation; verapamil is contraindicated in AV 

node dysfunction (2nd or 3rd degree heart block), systolic HF and lower LV 

function.

Diltiazem SRb 120-540 mg daily • Diltiazem may reduce sinus rate and cause heart block.

• Use CCBs with caution in patients with liver or kidney dysfunction

Combined Alpha-beta adrenergic blockers

Carvedilol IRb: 12.5-50 mg/day (divided bid) • Precautions for beta-blockers apply.

SRc: 20-80 mg/day

Labetalolc 200-800 mg/day (divided bid)

Peripherally Acting Adrenergic Agents

Reserpine 0.1-0.25 mg daily • Monitor for sedation, and nasal congestion.

• Reserpine not currently available in the U.S. due to changes in 

requirements for raw materials (re-verified 10/15/2014). Refer to FDA Drug 

Shortages for current information. 

Direct Acting Vasodilators

Minoxidil 2.5-100 mg/day (daily or divided bid) • Direct acting vasodilators often need concomitant use of diuretic and betablocker to reduce edema and reflex tachycardia. 

• Monitor for hypertrichosis and pericardial effusions with minoxidil. 

• Monitor for headache and SLE (dose-related) with hydralazine.

Hydralazineb 50-200 mg/day (divided bid)

Centrally Acting Antiadrenergic Drugs

Clonidine Tabletb 0.1-0.8 mg/day (divided bid) • Monitor for somnolence and dry mouth. Taper dose to discontinue.

Clonidine patch 0.1-0.3 mg patch weekly • Clonidine patches may be useful in selected Patients.

Methyldopa 500-2,000 mg/day (divided bid)

ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin II receptor blocker; AV=atrioventricular; bid=twice daily; CCB=calcium channel blockers; CKD=chronic kidney 

disease; CV=cardiovascular; HCTZ=hydrochlorothiazide; HF=heart failure; IR=immediate-release; K+=potassium; LV=left ventricular; SLE=systemic lupus erythematosus; 

SR=sustained-release

a. Partial list; refer to http://www.pbm.va.gov/nationalformulary.asp for items available on the VA National Formulary (VANF) and refer to http://pec.ha.osd.mil/formulary_search.

php?submenuheader=1 for items available on the DoD Uniform Formulary. All drugs listed are on the DoD Uniform Formulary.

b. DoD Basic Core Formulary (BCF) item.

c. Item not on VANF

d. Restricted to patients with chronic heart failure in VA.

e . Reserpine not currently available in the U.S. due to changes in requirements for raw materials (re-verified 10/15/2014; next available supply estimated March 2015). Refer to FDA 

Drug Shortages for current information.

 f. 12.5 mg may be considered as an initial dose with titration recommended to 25 to 50mg daily; refer to Recommendation 42 and associated discussion for further information.

g. Indapamide SR not currently available in the US.

h. For complete drug information, review the manufacturer’s prescribing information.
16 | Guideline Summary – 2014

REFERENCES

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A report from the American Heart Association. Circulation. Jan 1 2013;127(1):e6-e245.

2. Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood 

pressure control among United States adults with hypertension: The national health and 

nutrition examination survey, 2001 to 2010. Circulation. Oct 23 2012;126(17):2105-2114.

3. Smoley BA, Smith NL, Runkle GP. Hypertension in a population of active duty Service 

Members. J Am Board Fam Med. Nov-Dec 2008;21(6):504-511.

4. VA Health Services Research & Development. Spotlight: Hypertension and stroke. http://

www.hsrd.research.va.gov/news/feature/hypertension_stroke.cfm. Updated June 2011. 

Accessed October 27, 2014.

5. Fletcher RD, Amdur RL, Kolodner R, et al. Blood pressure control among US veterans: A 

large multiyear analysis of blood pressure data from the Veterans Administration health 

data repository. Circulation. May 22 2012;125(20):2462-2468.

6. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence 

to recommendations: The significance and presentation of recommendations. J Clin 

Epidemiol. Jul 2013;66(7):719-725.
http://www.healthquality.va.gov

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