Download Levels of evidence - CEFO-P-SD

2564-12-2011
ESC/EAS 2011 Guidelines
for the management of
dyslipidemias
1
European Heart Journal Advance Access
Published June 28, 2011
2
Classes of recommendations
Classes of recommendations
Classes of recommendations
Definition
Class I
‘Everybody agrees’
Evidence and/or general agreement
that a given treatment or procedure
is beneficial, useful, effective.
Class II
‘Not everybody agrees’
Conflicting evidence and/or a
divergence of opinion about the
usefulness/efficacy of the given
treatment or procedure.
Suggested wording to use
Is recommended/is indicated
Class IIa
Weight of evidence/opinion is in
favour of usefulness/efficacy.
Should be considered
Class IIb
Usefulness/efficacy is less well
established by evidence/opinion.
May be considered
Evidence or general agreement that
the given treatment or procedure is
not useful/effective, and in some
cases may be harmful.
Is not recommended
Class III
‘Everybody agrees’
3
Levels of evidence
Levels of evidence
Level of Evidence A
Data derived from multiple randomized
clinical trials
or meta-analyses.
Level of Evidence B
Data derived from single randomized
clinical trials
or large non-randomized studies.
Level of Evidence C
Consensus of opinion of the experts and/or small studies,
retrospective studies, registries.
4
Risque de maladies cardiovasculaires fatales
Risque à dix ans de maladies cardiovasculaires fatales pour la Belgique en fonction du sexe, de l’âge,
de la pression systolique, du cholestérol et du statut tabagique
Femme
Homme
5
Relative Risk Chart < 40y
This chart may be used to show younger people at low absolute risk that, relative to others in their age group,
their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of
smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication.
Please note that this chart shows RELATIVE not absolute risk. The risks are RELATIVE to 1 in the bottom left. Thus a
person in the top right hand box has a risk that is 12 times higher than a person in the bottom left.
ESC 2007
6
Recommendations for treatment targets for LDL-C
Recommendations
Classa
Levelb
Refc
I
A
15,32,33
In patients at VERY HIGH CV risk (established CVD, type 2
diabetes, type 1 diabetes with target organ damage, moderate
to severe CKD or a SCORE level ≥10%) the LDL-C goal is <1.8
mmol/L (less than ~70 mg/dL) and/or ≥ 50% LDL-C reduction
when target level cannot be reached.
aClass
of recommendation.
of evidence.
cReferences.
bLevel
CKD= chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease;
LDL-C = low-density lipoprotein-cholesterol
8
Recommendations for treatment targets for LDL-C
Classa
Levelb
Refc
In patients at HIGH CV risk
(markedly elevated single risk factors, a SCORE level ≥5 to
<10%) an LDL-C goal <2.5 mmol/L (less than ~100 mg/dL)
should be considered.
IIa
A
15,16,17
In subjects at MODERATE risk (SCORE level >1 to ≤5%) an
LDL-C goal < 3.0 mmol/L (less than ~115 mg/dL) should be
considered.
IIa
C
-
Recommendations
aClass
of recommendation.
of evidence.
cReferences.
bLevel
CKD= chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease;
LDL-C = low-density lipoprotein-cholesterol
9
Intervention strategies as a function of total CV risk
and LDL-C level
LDL-C levels
TOTAL CV risk
(SCORE) %
<70 mg/dL
<1.8 mmol/L
70 to <100 mg/dL
1.8 to <2.5 mmol/L
100 to <155 mg/dL
2.5 to < 4.0 mmol/L
155 to < 190 mg/dL
4.0 to < 4.9 mmol/L
<1
No lipid
intervention
No lipid
intervention
Lifestyle
intervention
Lifestyle
intervention
Classa/Levelb
I/C
I/C
≥ 1 to < 5
Lifestyle
intervention
Lifestyle
intervention
Classa/Levelb
I/C
I/C
>5 to <10, or
high risk
Lifestyle
intervention,
consider drug*
Lifestyle
intervention,
consider drug*
Classa/Levelb
IIa/A
≥10 or very high
risk
Lifestyle
intervention,
consider drug*
Classa/Levelb
IIa/A
IIa/A
Lifestyle
intervention, and
immediate drug
intervention
IIa/A
I/C
Lifestyle
intervention,
consider drug if
uncontrolled
IIa/A
Lifestyle
intervention, and
immediate drug
intervention
IIa/A
Lifestyle
intervention, and
immediate drug
intervention
I/A
I/C
Lifestyle
intervention,
consider drug if
uncontrolled
IIa/A
Lifestyle
intervention, and
immediate drug
intervention
I/A
Lifestyle
intervention, and
immediate drug
intervention
I/A
>190 mg/dL
>4.9 mmol/L
Lifestyle
intervention,
consider drug if
uncontrolled
IIa/A
Lifestyle
intervention,
consider drug if
uncontrolled
I/A
Lifestyle
intervention, and
immediate drug
intervention
I/A
Lifestyle
intervention, and
immediate drug
intervention
I/A
*In
patients with MI, statin therapy should be considered irrespective of LDL-C levels.
of recommendation.
bLevel of evidence.
aClass
CV = cardiovascular; LDL-C = low-density lipoprotein-cholesterol; MI = myocardial infarction.
10
Addendum II. Practical approach to reach LDL-C goal
Percentage reduction of LDL-C requested to achieve goals as a function of the starting value
Starting LDL-C
% Reduction to reach LDL-C
mmol/L
~mg/mL
<1.8 mmol/L
(~70mg/dL)
<2.5 mmol/L
(~100mg/dL)
<3 mmol/L
(~115mg/dL)
>6.2
>240
>70
>60
>55
5.2-6.2
200-240
65-70
50-60
40-55
4.4-5.2
170-200
60-65
40-50
30-45
3.9-4.4
150-170
55-60
35-40
25-30
3.4-3.9
130-150
45-55
25-35
10-25
2.9-3.4
110-130
35-45
10-25
<10
2.3-2.9
90-110
22-35
<10
-
1.8-2.3
70-90
<22
-
-
11
12
LDL-C
LDL-C: Percentage Change from Baseline
at Week 6 (n=2240)
Dose (mg)
LS mean % change from baseline
0
10
20
40
80
Log scale
-10
-20
-30
-40
-50
-60
rosuvastatin
Jones et al. Am J Cardiol 2003: 93: 152-160
atorvastatin
simvastatin
pravastatin
13
SCORE
2011
Women
High
Risk
14
HDL-C: Percentage Change from Baseline
at Week 6 (n= 2240)
LS mean % change from baseline
12
10
8
6
4
2
0
10
rosuvastatin
Jones et al. Am J Cardiol 2003: 93: 152-160
20
Dose (mg)
atorvastatin
40
simvastatin
80
Log scale
pravastatin
15
l’effet du cholestérol associé aux lipoprotéines
de haute densité (HDL-C) sur le risque CV global
Taux
HDL-C, mg/dl
Femme
Homme
30
38
46
54
62
70
x 1,8 x 1,5 x 1,2 x 1
x 0,8 x 0,7
x 1,3 x 1,1 x 1 x 0,9 x 0,8 x 0,7
16
Statins
Efficacy in clinical studies
Statins are among the most studied drugs in CV prevention, and dealing with
single studies is beyond the scope of the present guidelines.
A number of large-scale clinical trials have demonstrated that statins
substantially reduce CV morbidity and mortality in both primary and secondary
prevention. Statins have also been shown to slow the progression or even
promote regression of coronary atherosclerosis.
17
Statins
Meta-analyses
Current available evidence suggests that the clinical benefit is largely
independent of the type of statin but depends on the extent of LDL-C lowering;
therefore, the type of statin used should reflect the degree of LDL-C reduction
that is required to reach the target LDL-C in a given patient. More details on this
are provided in Addendum II to these guidelines.
18
Statins
Meta-analyses - Type 2 Diabetes
The recent finding that the incidence of diabetes may increase with statins
should not discourage institution of treatment; the absolute reduction in the
risk of CVD in high risk patients outweighs the possible adverse effects of a very
small increase in the incidence
of diabetes.
19
Cholesterol absorption inhibitors
Efficacy in clinical studies
Ezetimibe can be used as second-line therapy in association with statins when
the therapeutic target is not achieved at maximal tolerated statin dose or in
patients intolerant of statins or with contraindications to these drugs.
20
Management of hypertriglyceridaemia
Pharmacological therapy
As statins have significant effects on mortality as well as most CVD outcome
parameters, these drugs are the first choice to reduce both total CVD risk and
moderately elevated TG levels. More potent statins (atorvastatin, rosuvastatin,
and pitavastatin) demonstrate a robust lowering of TG levels, especially at high
doses and in patients with elevated TG.
21
Le risque sera également plus élevé qu’indiqué
dans les tableaux pour :
• Les personnes socialement défavorisées ; les privations induisent de
nombreux autres facteurs de risque.
• Les sujets sédentaires et ceux présentant une obésité abdominale ;
ces caractéristiques déterminent de nombreux autres aspects des
risques énumérés ci-dessous.
• Les personnes diabétiques : une nouvelle analyse de la base de données
SCORE indique que les personnes présentant un diabète avéré ont un
risque nettement plus élevé ; cinq fois plus élevé pour les femmes et
trois fois plus élevé pour les hommes.
• Les personnes ayant un faible taux d’HDL-C ou d’apolipoprotéine A1
(apo A1), des taux élevés de TG, de fibrinogène, d’homocystéine,
d’ apolipoprotéine B (apo B) et de lipoprotéine(a) (Lp(a)), une
hypercholestérolémie familiale (HF) ou un taux élevé de hs-CRP ;
ces facteurs indiquent un niveau de risque accru pour les deux sexes,
pour toutes les tranches d’âge et pour tous les niveaux de risque.
23
• Les personnes asymptomatiques présentant des signes précliniques
d’athérosclérose, par exemple la présence de plaques ou un
épaississement de l’intima–média carotidienne détecté lors d’une
échographie carotidienne.
• Les personnes atteintes d’insuffisance rénale.
• Les personnes ayant des antécédents familiaux de MCV précoce dont
on considère qu’ils multiplient le risque par 1,7 chez les femmes et par
2,0 chez les hommes.
• À l’inverse, le risque peut être inférieur à celui indiqué chez les
personnes ayant des taux très élevés d’HDL-C ou des antécédents
familiaux de longévité.
24
Risk factor management in coronary
patients – results from a European
wide survey
EUROASPIRE III
Professor David A Wood
on behalf of the EUROASPIRE Investigators
25
Distribution of Age, Gender and Diagnostic Category
100
90
80
Gender
Age
Diagnostic category
70
60
50
40
30
20
10
0
Women
(%)
Mean age
(years)
Age < 60
yrs
CABG
PTCA
(%)
(%)
(%)
AMI
(%)
ISCHAEMIA
(%)
Survey 1
24,9
59,3
47,8
25,6
25,6
25,8
23,0
Survey 2
25,2
59,4
48,1
24,8
27,8
26,1
21,2
Survey 3
23,1
60,9
40,6
28,3
49,8
9,9
12,0
26
Prevalence of Smoking*
* Self-reported smoking or CO in breath > 10 ppm
100%
90%
80%
S2 vs. S1 : P=0.83
S3 vs. S2 : P=0.37
S3 vs. S1 : P=0.48
70%
60%
50%
40%
P=0.64
30%
20%
10%
0%
Czech
Rep.
Finland
Survey 1
22,0%
12,8%
25,0%
16,8%
23,3%
18,6%
31,8%
13,3%
20,3%
Survey 2
19,3%
21,6%
24,2%
16,8%
30,1%
15,1%
28,3%
14,6%
21,2%
Survey 3
22,2%
16,8%
24,8%
18,4%
18,3%
14,0%
15,1%
12,0%
18,2%
France Germany Hungary
Italy
NetherSlovenia
lands
ALL
27
Prevalence of Overweight*
* Body mass index ≥ 25 kg/m²
S2 vs. S1 : P=0.15
S3 vs. S2 : P=0.22
S3 vs. S1 : P=0.02
100%
P=0.04
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
NetherSlovenia
lands
Czech
Rep.
Finland
Survey 1
81,3%
79,3%
75,8%
82,4%
71,0%
81,4%
70,5%
73,8%
76,8%
Survey 2
87,0%
78,4%
79,7%
82,7%
79,2%
71,7%
78,5%
78,7%
79,9%
Survey 3
84,6%
77,2%
77,1%
85,3%
85,6%
81,3%
78,9%
84,4%
82,7%
France Germany Hungary
Italy
ALL
28
Prevalence of Obesity*
* Body mass index ≥ 30 kg/m²
S2 vs. S1 : P=0.009
S3 vs. S2 : P=0.051
S3 vs. S1 : P=0.0002
100%
90%
80%
70%
60%
P=0.0006
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
Survey 1
31,4%
29,6%
33,4%
23,0%
23,3%
22,4%
18,9%
19,2%
25,0%
Survey 2
40,1%
33,6%
37,5%
30,6%
36,8%
23,6%
28,2%
28,0%
32,6%
Survey 3
37,9%
26,4%
36,8%
43,1%
49,3%
29,4%
26,5%
39,1%
38,0%
France Germany Hungary
Italy
NetherSlovenia
lands
ALL
29
Prevalence of Raised Blood Pressure (1)*
* SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg
S2 vs. S1 : P=0.83
S3 vs. S2 : P=0.51
S3 vs. S1 : P=0.65
100%
90%
80%
P=0.79
70%
60%
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
Italy
Nether
lands
Slovenia
ALL
Survey 1
60,1%
56,1%
48,4%
58,4%
50,6%
55,3%
54,0%
55,1%
54,6%
Survey 2
46,9%
52,0%
55,5%
67,0%
40,4%
50,8%
54,4%
62,8%
54,0%
Survey 3
62,5%
67,1%
48,1%
50,9%
46,3%
60,5%
59,6%
55,1%
55,2%
France Germany Hungary
30
Therapeutic Control of Blood Pressure*
* SBP/DBP < 140/90 mmHg for non-diabetics or < 130/80 mmHg for diabetics
100%
90%
S2 vs. S1 : P=0.98
S3 vs. S2 : P=0.36
S3 vs. S1 : P=0.37
80%
70%
P=0.57
60%
50%
40%
30%
20%
10%
0%
Czech Rep.
Finland
France
Germany
Hungary
Italy
Netherlands Slovenia
ALL
Survey 1
34,4%
39,1%
47,9%
39,7%
44,0%
41,0%
43,3%
37,7%
41,0%
Survey 2
47,2%
43,4%
36,7%
29,1%
55,0%
45,7%
43,5%
31,1%
41,2%
Survey 3
30,1%
29,1%
44,1%
45,2%
44,1%
34,8%
35,3%
41,4%
38,7%
31
Prevalence of Raised Total Cholesterol*
* Total cholesterol ≥ 4.5 mmol/L
S2 vs. S1 : P<0.0001
S3 vs. S2 : P<0.0001
S3 vs. S1 : P<0.0001
P<0.0001
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
94,2%
93,7%
91,5%
94,3%
97,4%
96,9%
97,1%
95,5%
94,5%
Survey 2
86,1%
63,8%
79,3%
83,4%
54,5%
72,5%
66,7%
82,2%
76,7%
Survey 3
47,1%
28,2%
40,8%
49,4%
57,0%
48,8%
33,1%
41,8%
46,2%
32
Therapeutic Control of Total Cholesterol*
100%
* Total cholesterol < 4.5 mmol/L
S2 vs. S1 : P<0.0001
S3 vs. S2 : P<0.0001
S3 vs. S1 : P<0.0001
90%
80%
P<0.0001
70%
60%
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
4,6%
6,8%
14,2%
9,6%
4,8%
0,0%
7,9%
8,1%
8,4%
Survey 2
17,3%
46,2%
23,4%
20,5%
31,4%
31,1%
40,0%
22,0%
28,7%
Survey 3
55,8%
72,6%
62,4%
54,0%
48,7%
53,2%
68,9%
60,3%
57,3%
33
Prevalence of Diabetes*
* Self-reported history of diagnosed diabetes
100%
90%
S2 vs. S1 : P=0.21
S3 vs. S2 : P=0.02
S3 vs. S1 : P=0.001
80%
70%
60%
P=0.004
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
21,8%
15,4%
16,7%
13,5%
26,6%
17,2%
10,3%
17,4%
17,4%
Survey 2
21,5%
18,7%
27,5%
13,5%
21,1%
21,8%
13,2%
23,8%
20,1%
Survey 3
30,8%
19,1%
34,2%
22,6%
44,8%
21,7%
20,6%
18,8%
28,0%
34
Therapeutic Control of Diabetes*
* Fasting glucose < 7 mmol/L in patients with history of diabetes
100%
S2 vs. S1 : P=0.82
S3 vs. S2 : P=0.03
S3 vs. S1 : P=0.08
90%
80%
70%
60%
50%
P=0.04
40%
30%
20%
10%
0%
Czech
Rep.
Finland
Survey 1
38,7%
34,4%
Survey 2
29,9%
30,8%
Survey 3
17,2%
40,0%
France
Germany
Hungary
Italy
15,1%
71,4%
20,4%
26,9%
42,3%
53,2%
27,8%
18,7%
25,4%
10,2%
Netherlands
Slovenia
ALL
48,6%
39,1%
70,7%
72,7%
42,1%
33,3%
20,0%
21,5%
35
Medication Use: Antiplatelets
S2 vs. S1 : P=0.29
S3 vs. S2 : P=0.0002
S3 vs. S1 : P<0.0001
P<0.0001
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
85,2%
82,2%
82,1%
82,9%
72,0%
86,1%
77,5%
79,4%
80,8%
Survey 2
87,6%
81,9%
85,7%
86,3%
75,1%
91,5%
81,0%
82,3%
83,6%
Survey 3
92,5%
96,4%
98,1%
91,8%
86,1%
98,0%
95,7%
92,4%
93,2%
36
Medication Use: Beta-Blockers
S2 vs. S1 : P=0.001
S3 vs. S2 : P=0.0002
S3 vs. S1 : P<0.0001
100%
P<0.0001
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
65,3%
77,8%
56,3%
43,6%
57,7%
49,2%
46,8%
51,8%
56,0%
Survey 2
73,7%
87,9%
60,4%
68,1%
84,3%
61,2%
48,2%
65,7%
69,0%
Survey 3
91,3%
95,8%
74,4%
85,0%
85,9%
87,6%
74,6%
87,0%
85,5%
37
Medication Use: ACE Inhibitors & Angiotensin II RA
S2 vs. S1 : P<0.0001
S3 vs. S2 : P<0.0001
S3 vs. S1 : P<0.0001
100%
P<0.0001
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Czech Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
28,1%
17,3%
33,8%
31,4%
46,3%
31,8%
27,4%
31,2%
31,0%
Survey 2
47,1%
31,0%
43,7%
50,6%
58,6%
53,5%
42,9%
63,0%
49,2%
Survey 3
76,1%
59,3%
78,9%
72,8%
80,6%
70,9%
66,5%
83,0%
74,6%
38
Medication Use: Statins
S2 vs. S1 : P<0.0001
S3 vs. S2 : P<0.0001
S3 vs. S1 : P<0.0001
100%
P<0.0001
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Czech Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
6,3%
34,9%
20,2%
31,1%
6,7%
6,8%
14,0%
23,2%
18,1%
Survey 2
38,8%
62,6%
61,0%
65,6%
45,2%
57,0%
75,1%
56,3%
57,3%
Survey 3
88,1%
95,2%
89,1%
85,4%
76,7%
90,0%
91,4%
90,1%
87,0%
39
Medication Use: Diuretics
100%
S2 vs. S1 : P=0.30
S3 vs. S2 : P=0.02
S3 vs. S1 : P=0.002
90%
80%
70%
60%
50%
P=0.006
40%
30%
20%
10%
0%
Czech Rep.
Finland
France
Germany
Hungary
Italy
Nether-lands
Slovenia
ALL
Survey 1
15,7%
12,0%
18,7%
14,5%
15,9%
17,6%
13,7%
14,3%
15,3%
Survey 2
22,7%
12,4%
13,2%
32,7%
23,9%
16,3%
12,6%
14,3%
18,8%
Survey 3
36,3%
10,8%
19,2%
33,8%
52,6%
20,4%
23,2%
29,1%
31,1%
40
Conclusions
 No change in blood pressure control despite
increased use of anti-hypertensive medications

61% above therapeutic target
 (BP < 140/90 mmHg)
 Continuing improvement in lipid control with
increased use of statins
 42% above the 2003 therapeutic target (TC < 4.5
mmol/l)
41
Goals of treatment
-BP < 140/90 mmHg in all hypertensive
patients
< 130/80 mmHg in hypertensive
patients
with diabetes or renal disease
-Control of all cardiovascular risk
factors
ESH - ESC Guidelines, J Hypertens 2003
42
Patient 1
Patient 2
Patient 3
Sympathetic
nervous
system
Renin-angiotensin
system
Total body sodium
43
Percentage of patients with
normal blood pressure
Drug A
Drug B
Drugs
C
0
20
40
60
80
100
%
44
BP control rate during antihypertensive monotherapy
Achieved BP:
<140/90 mmHg
80
60
% 40
39
20
0
During monotherapy
(diuretic, b-blocker, ACE inhibitor or Ca antagonist)
Dickerson et al, Lancet, 1999
45
Percentage of patients with
normal blood pressure
Drug A
Drug B
Drugs A +
B
0
20
40
60
80
100
%
46
Effects of two different drugs on BP
separately and in combination
(119 randomized placebo controlled trials)
Placebosubtracted BP
response. mmHg
0
"First"
drug
alone
"Second"
drug
alone
Combinati
on
-5
-10
-5
Systolic
Diastolic
Law et al, BMJ
200347
Advantages of fixed versus liberal
combinations of two antihypertensive
drugs
Fixed
*
Liberal
Simplicity of treatment
+
-
Compliance
+
-
Efficacy
+
+
Tolerability
+*
-
Price
+
-
Flexibility
-
+
Risk of administering
contraindicated drug
+
-
lower doses generally used in fixed-dose combinations
48
Pharmacological treatment of hypertension
Consider :
Blood pressure level before treatment
Absence or presence of TOD and risk
factors
Choose between :
Single agent at low
dose
Previous
agent at
full dose
Two-drug combination at low
dose
If goal BP not achieved :
Switch to
Previous
different
combinati
agent at low
on at full
If goal BP not achieved :
dose
dose
Two-three drug
combination
Add a
third drug
at low
dose
Two-three drug
combination
2003 European Society of Hypertension - European Society of Cardiology
Guidelines for the Management of Arterial Hypertension, J Hypertens, 2003
49
Algorithm for treatment of hypertension
Lifestyle modifications
Not at goal BP (<140/90 mmHg or <130/80 mmHg for those with diabetes or chronic kidney
disease)
Initial drug choices
Hypertension without compelling indications
Stage 1 hypertension
(SBP 140-159 or DBP 90-99
mmHg)
Thiazide-type diuretics for
most, consider ACE inhibitor,
ARB, b-blocker, CCB, or
combination
Hypertension with compelling indications
Stage 2 hypertension
(SBP ≥160 mmHg or DBP ≥100
mmHg)
2-drug combination for most
(usually thiazide-type diuretic
and ACE inhibitor or ARB or bblocker or CCB)
Drug(s) for the
compelling indications
Other antihypertensive
drugs (diuretics, ACE
inhibitor, ARB,
b-blocker, CCB) as
needed
Not at goal BP
Optimize dosages or add additional drugs until goal BP is achieved
Consider consultation with hypertension specialist
The JNC VII Report, 2003
50
Normalization
of BP
Good
tolerability
Simple drug
regimen
SATISFACTION
Day-to-day compliance 
Long-term compliance 
51