Clinical Review & Education

JAMA | Review

Treatment of Hypertension
A Review
Robert M. Carey, MD; Andrew E. Moran, MD; Paul K. Whelton, MB, MD, MSc

Multimedia
IMPORTANCE Hypertension, defined as persistent systolic blood pressure (SBP) at least
130 mm Hg or diastolic BP (DBP) at least 80 mm Hg, affects approximately 116 million adults
in the US and more than 1 billion adults worldwide. Hypertension is associated with increased
risk of cardiovascular disease (CVD) events (coronary heart disease, heart failure, and stroke)
and death.

OBSERVATIONS First-line therapy for hypertension is lifestyle modification, including weight

loss, healthy dietary pattern that includes low sodium and high potassium intake, physical
activity, and moderation or elimination of alcohol consumption. The BP-lowering effects of
individual lifestyle components are partially additive and enhance the efficacy of
pharmacologic therapy. The decision to initiate antihypertensive medication should be based
on the level of BP and the presence of high atherosclerotic CVD risk. First-line drug therapy
for hypertension consists of a thiazide or thiazidelike diuretic such as hydrochlorothiazide or
chlorthalidone, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker
such as enalapril or candesartan, and a calcium channel blocker such as amlodipine and
should be titrated according to office and home SBP/DBP levels to achieve in most people an
SBP/DBP target (<130/80 mm Hg for adults <65 years and SBP <130 mm Hg in adults ⱖ65 Author Affiliations: Division of
Endocrinology and Metabolism,
years). Randomized clinical trials have established the efficacy of BP lowering to reduce the
Department of Medicine, University
risk of CVD morbidity and mortality. An SBP reduction of 10 mm Hg decreases risk of CVD of Virginia Health System,
events by approximately 20% to 30%. Despite the benefits of BP control, only 44% of US Charlottesville (Carey); Division of
adults with hypertension have their SBP/DBP controlled to less than 140/90 mm Hg. General Medicine, Department of
Medicine, Columbia University Irving
CONCLUSIONS AND RELEVANCE Hypertension affects approximately 116 million adults in the Medical Center, New York, New York
(Moran); Departments of
US and more than 1 billion adults worldwide and is a leading cause of CVD morbidity and
Epidemiology and Medicine, Tulane
mortality. First-line therapy for hypertension is lifestyle modification, consisting of weight University Health Sciences Center,
loss, dietary sodium reduction and potassium supplementation, healthy dietary pattern, New Orleans, Louisiana (Whelton).
physical activity, and limited alcohol consumption. When drug therapy is required, first-line Corresponding Author: Robert M.
therapies are thiazide or thiazidelike diuretics, angiotensin-converting enzyme inhibitor or Carey, MD, University of Virginia
Health System, PO Box 801414,
angiotensin receptor blockers, and calcium channel blockers.
Charlottesville, VA 22908-1414
([email protected]).
JAMA. 2022;328(18):1849-1861. doi:10.1001/jama.2022.19590 Section Editor: Mary McGrae
McDermott, MD, Deputy Editor.

H
ypertension, a major risk factor for cardiovascular mor- National Health and Nutrition Examination Survey (NHANES) that
bidity and mortality, is defined by the 2017 American Col- included 18 262 US adults demonstrated that the age-adjusted per-
lege of Cardiology (ACC)/American Heart Association centage of the general adult population with hypertension (defined
(AHA) guideline as systolic blood pressure (SBP) at least 130 mm Hg in the report as SBP ⱖ140 mm Hg, DBP ⱖ90 mm Hg, or taking
or diastolic BP (DBP) at least 80 mm Hg, or reported treatment with antihypertensive medication) whose SBP/DBP was controlled to
antihypertensive medication.1,2 The prevalence of hypertension in less than 140/90 mm Hg was 48.5% in 2007-2008, 53.8% in 2013-
US adults is approximately 44% to 49%.3,4 Based on self-reported 2014, and 43.7% in 2017-2018.8 This Review summarizes current
data from a survey of hypertension prevalence in 533 306 adults, it evidence regarding treatment of hypertension, emphasizing the
was estimated that eliminating hypertension in women would re- 2017 ACC/AHA high BP guideline recommendations.2
duce population mortality by approximately 7.3% compared with
0.1% for hyperlipidemia, 4.1% for diabetes, 4.4% for cigarette smok-
ing, and 1.7% for obesity.5 Eliminating hypertension in men would
Methods
reduce population mortality by approximately 3.8% compared with
2.0% for hyperlipidemia, 1.7% for diabetes, 5.1% for cigarette smok- We searched the PubMed database for studies in English published
ing, and 2.6% for obesity.5 since release of the 2017 ACC/AHA BP guideline from January 2018
Despite the well-established risks of hypertension and bene- to September 2022. References of selected articles were manually
fits of antihypertensive treatment,6,7 an analysis of data from the searched for additional relevant studies. Emphasis was given to

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 Clinical Review & Education Review Review of Hypertension Treatment

randomized clinical trials, systematic reviews and meta-analyses, that randomized participants with a history of stroke or aged 60 years
clinical practice guidelines, scientific statements, and articles rel- or older and with high BP in clusters (villages) to either a salt substi-
evant to general medical practice. Of 457 reports identified, 45 were tute (75% sodium chloride and 25% potassium chloride) or contin-
included, consisting of 18 randomized trials, 15 meta-analyses, 2 lon- ued regular salt reported significantly lower rates of stroke (29 vs 34
gitudinal observational studies, 6 cross-sectional studies, and 4 sci- events per 1000 person-years), major cardiovascular events (49 vs
entific statements. 56 events per 1000 person-years), and death from any cause (39 vs
45 events per 1000 person-years) in those randomized to salt
substitute.31 Rates of serious adverse events attributed to hyperka-
lemia were not significantly different in the salt substitute and regu-
Nonpharmacologic Management of Hypertension
lar salt groups (3 vs 3 events per 1000 person-years). However, the
Established nonpharmacologic interventions for the prevention and results of this study may not be entirely applicable in the US, where a
treatment of hypertension are losing weight, reducing dietary so- larger proportion of sodium is consumed in processed foods as op-
dium, increasing potassium intake, consuming a heart-healthy diet, posed to salt added during cooking or eating.
engaging in physical activity, and reducing alcohol consumption
(Table 1).10-23 Although difficult to achieve and sustain, behavior Whole Dietary Patterns
change is feasible, especially in motivated patients counseled by Heart-healthy diets, such as the Mediterranean diet and Dietary Ap-
trained professionals with clinician reinforcement. Each of these in- proaches to Stop Hypertension (DASH), consist of whole grains, veg-
terventions can reduce mean SBP by approximately 5 mm Hg in adults etables, legumes, fish, olive oil, fruits, nuts, seeds, herbs, and mod-
with hypertension and approximately 2 to 3 mm Hg in adults with- erate alcohol consumption (defined as ⱕ1 standard drink per day for
out it.2 Greater BP reductions are possible in individuals with a higher women and ⱕ2 for men). In 1 clinical trial, 459 people with mean BP
initial BP when lifestyle interventions are combined.24-26 Nonphar- at baseline of 132/85 mm Hg were randomized to a diet high in fruits
macologic interventions also augment BP lowering by pharmaco- and vegetables (n = 154); a DASH diet high in fruits and vegetables and
logic agents, including in patients with drug-resistant hypertension. low-fat dairy foods and low in saturated fat, total fat, and cholesterol
A reasonable approach is to implement the intervention(s) most likely (n = 151); or a control diet typically consumed by US adults (n = 154).18
to be successful, based on lifestyle factors that are most suboptimal The diets were prepared in a research kitchen and participants were
and on the patient’s willingness to adopt the intervention(s). asked not to eat other foods. After 8 weeks of adherence to the as-
signed diets, changes in SBP/DBP were −2.7/−1.9 mm Hg in the fruits
Weight Loss and vegetables diet group and −5.5/−3.0 mm Hg in the DASH diet
Weight loss is best achieved by combining calorie reduction and group compared with the control group. In the subgroup with hyper-
physical activity.27 The ideal approach is gradual and results in du- tension, the SBP/DBP changes were −7.3/−2.9 mm Hg in the DASH
rable weight loss, with a weekly reduction goal of 1 to 2 kg. An SBP group compared with the control group.
reduction of approximately 1 mm Hg is expected for every kilogram
of weight lost.11 Among individuals with obesity and hypertension Physical Activity
who meet the appropriate criteria (body mass index >35 [calcu- Most clinical trials demonstrating a BP-lowering effect of physical
lated as weight in kilograms divided by height in meters squared] activity have used aerobic exercise such as brisk walking, swim-
and poorly controlled hypertension), bariatric surgery can induce ming, dancing, or gym exercises. However, dynamic resistance ex-
substantial weight loss and meaningfully improve BP.28 ercise such as hand grip or yoga is also beneficial.33 Medium- to high-
intensity exercise, such as running, and low-intensity aerobic
Dietary Sodium and Potassium Intake exercise, such as walking, can lower BP.34 According to clinical trial
Any decrease in sodium intake is helpful because the association be- evidence, an exercise duration of 40 to 60 minutes at least 3 times
tween sodium and BP reduction is approximately linear, with a per week may be optimal for BP lowering.34
1000-mg sodium reduction resulting in SBP lowering of approxi-
mately 3 mm Hg.15,25,29,30 As an optimal target, clinicians can rec- Alcohol Consumption
ommend sodium intake of less than 1500 mg/d.2 Eating patterns as- Epidemiologic studies have repeatedly documented a progressive, di-
sociated with lowering dietary sodium intake include eating fresh rect, quantitative, dose-response relationship between alcohol con-
rather than processed foods, reducing portion size, avoiding foods sumption and level of BP, as well as the incidence of hypertension.35
especially high in sodium content, reading food labels for pack- It is reasonable to continue small amounts of alcohol (ⱕ2 drinks daily
aged and prepared foods, choosing condiments and seasonings with for men and ⱕ1 for women), but alcohol consumption should not be
low sodium content, and attempting sodium substitutions by using encouraged because of the risk of accidents, injuries, and liver dis-
herbs, spices, or potassium-enriched salt substitutes.31 ease and the potential for alcohol dependency.2
Randomized clinical trials have demonstrated that potassium
supplementation significantly lowers BP.32 Most clinical trials dem-
onstrating benefit added approximately 60 mmol/d. However, in- Role of Cardiovascular Disease Risk in the
creasing foods high in potassium (ie, fruits and vegetables) is pre-
Management of Adults With High BP
ferred because of the additional health benefits associated with this
change. Potassium supplementation has greater effects on BP in In prospective observational studies, mean SBP was directly asso-
people with a higher initial BP, people who are Black, and those con- ciated with risk of atherosclerotic cardiovascular disease (ASCVD)
suming sodium at more than 2500 mg/d.32 A clinical trial in rural China across SBP ranging from 90 to 180 mm Hg.36-38 However, at any level

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 Table 1. Most Effective Nonpharmacologic Interventions to Lower Blood Pressure

Lifestyle characteristic Association with high BP Intervention Regimen/dosage Expected BP improvement

jama.com
Weight loss Prevalence of overweight (BMI 25-<30) Combined calorie reduction and physical Achieving ideal weight is optimal, but any In a meta-analysis of 25 randomized
and obesity (BMI ≥30) in US adults: >70% activity, preferably provided by someone reduction in weight is beneficial clinical trials, average weight loss was
(>40% obesity)10 trained to deliver behavioral interventions In most clinical trials, an average ≈4.5-kg 5.1 kg (11.2 lb) and average reduction
(10-lb) weight loss has been achieved with in SBP/DBP was 7.00/5.49 mm Hg in
behavior-change interventions, but patients treated with antihypertensive
long-term maintenance of weight loss has medication and 3.77/2.97 mm Hg in
been challenging those who were not11
When expressed per kilogram of
Review of Hypertension Treatment

weight loss, the reductions in SBP/DBP

were 1.05/0.92 mm Hg
In a meta-analysis of 10 prospective cohort Bariatric surgery reserved for individuals with In a single-center trial (N = 144),
studies (N = 173 828), the risk ratio of BMI ≥40 or ≥35 with ≥1 obesity-related addition of weight loss to the DASH
hypertension in adults with overweight and comorbidity diet resulted in an additional SBP/DBP
obesity compared with normal weight was reduction of 4.9/2.4 mm Hg at 4 mo
1.52 and 2.17, respectively9
Sodium intake In the INTERSALT cross-sectional study Reduced dietary sodium consumption The ACC/AHA recommends an optimal Meta-analyses of sodium reduction
(10 079 adults; 32 countries), increased counseling, preferably provided by someone sodium intake of <1500 mg/d trials have identified an SBP reduction
sodium intake of 2300 mg/d (100 mmol) trained to deliver behavioral interventions The USDA Dietary Guidelines for Americans of ≈5 mm Hg for adults with
was associated with a level of SBP 3-6 mm Hg recommends <2300 mg/d and the WHO hypertension and 2.5 mm Hg in adults
14
higher recommends <2000 mg/d without it13
Most US adults consume sodium well in Dose-response meta-analysis has
excess of these recommendations. Because identified an approximately linear
of the linear dose-response relationship association, with a 1000-mg
between sodium intake and BP, any reduction in dietary sodium resulting
reduction in sodium intake is beneficial in ≈3- and 1-mm Hg SBP reduction in
adults with and without hypertension,
respectively15
In a 2005-2010 NHANES analysis, SBP was Elements for success:
2.4 mm Hg higher for a sodium intake that selecting food carefully, favoring fresh foods
was higher by 2300 mg12 and minimizing processed foods and those
known to be high in salt content;
reading food labels when purchasing food
products;
moderating portion size;
using salt substitutes such as potassium-rich
salts, herbs;
minimizing fast food or sit-down restaurant

© 2022 American Medical Association. All rights reserved.

food consumption;
requesting no added salt when ordering
The INTERSALT investigators suggested that
every year of exposure to a daily sodium
intake increase of 2300 mg might result in an
increase of 0.5 mm Hg in SBP, partly
explaining the age-related increase in BP
common in most populations

(continued)

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 1852
Table 1. Most Effective Nonpharmacologic Interventions to Lower Blood Pressure (continued)

Lifestyle characteristic Association with high BP Intervention Regimen/dosage Expected BP improvement

Potassium intake In the INTERSALT study, a daily potassium Fruits, leafy greens, beans, nuts, dairy foods, A potassium intake of 3500-5000 mg/d, Meta-analyses have repeatedly
intake increase of 50 mmol (1955 mg) was and starchy vegetables (potatoes, winter preferably through diet, is the optimal documented a BP-lowering effect of
associated with a decrease in SBP squash) are a rich source of potassium approach but any increase is good potassium supplementation, whether
of 3.4 mm Hg The DASH diet provides potassium at achieved by diet or pill
4700 mg/d. Potassium pill supplements supplementation
(60 mmol/d) are effective for BP lowering but In a 2017 meta-analysis of 25
do not provide the additional benefits of randomized clinical trials, SBP and
a dietary supplementation approach DBP were reduced by an average of
4.5 and 3.0 mm Hg, respectively16
Clinical Review & Education Review

In a meta-analysis of 32 trials, a
nonlinear U-shaped dose-response
relationship was identified but there
were only a limited number of trials
informing the upper end of the
relationship17
In the 2005-2010 NHANES report, the fully
adjusted equivalent was a decrease in SBP of
2.4 mm Hg for a daily potassium intake
increase of 50 mmol (1955 mg)
Whole dietary patterns Many observational studies have documented DASH specifically maximizes BP lowering, The DASH diet is high in fruits, vegetables, In an 8-wk feeding study, the DASH

JAMA November 8, 2022 Volume 328, Number 18 (Reprinted)

lower BP in adults consuming a vegetarian but all vegetarian diets tend to lower BP, and whole grains diet lowered SBP/DBP by
compared with nonvegetarian diet and have whether specific or a component of It allows for consumption of fat-free or 5.5/3.0 mm Hg18
suggested that vegetarians experience heart-healthy diets such as Mediterranean, low-fat dairy products, fish, and poultry
a lower age-related increase in BP vegan, or low carbohydrate
The standard DASH diet contains sodium at
Vegetarian individuals tend to exhibit ≈2300 mg/d
lifestyle characteristics that favor a lower BP,
making it difficult to estimate the Dose-response meta-analyses have
quantitative role of nonvegetarian dietary demonstrated a significant association
consumption as a cause of hypertension between DASH diet adherence and risk of
stroke, as well as all-cause and cause-specific
mortality
In a 6-mo behavioral intervention
trial, the DASH diet reduced SBP/DBP
by 4.3/2.6 mm Hg compared with
advice only, and by 0.6/0.9 mm Hg
compared with “established
recommendations (weight loss,
physical activity, reduced sodium

© 2022 American Medical Association. All rights reserved.

intake, and moderation in alcohol
consumption)”19
Physical activity In a meta-analysis of 29 longitudinal cohort Most physical activity, including aerobic Common forms of aerobic exercise include In a network meta-analysis of 391
studies (330 222 adults with 67 698 cases of (endurance) and resistance (strength) brisk walking, running, swimming, dancing, trials (197 evaluating exercise and
incident hypertension during follow-up), exercises, lowers BP gym workout, or some combination 5-7 194 evaluating antihypertensive drug
both leisure time and total physical activity times/wk (approximately 30-60 min/session; therapy), SBP was reduced, compared
demonstrated an inverse linear association ≥150 min/wk), with gradual start/warm-up with control, by 4.88 mm Hg with
with the risk of incident hypertension, with and postexercise cool-down21 aerobic exercise, 3.50 mm Hg with
the risk being 6% lower in those who met the Many studies have documented clinically resistance exercise, and 6.49 mm Hg
minimal level of physical activity important reductions in BP with physical with the combination
recommended in guidelines (exercise at activity of only modest intensity. In patients with hypertension, the BP
150 min/wk) compared with those who were reduction magnitude was similar to
inactive20 that obtained with different
antihypertensive medications (average
SBP difference = 0.18 mm Hg)21

(continued)

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Review of Hypertension Treatment
 Table 1. Most Effective Nonpharmacologic Interventions to Lower Blood Pressure (continued)

Lifestyle characteristic Association with high BP Intervention Regimen/dosage Expected BP improvement

jama.com
Most trials have used aerobic exercise, most Common forms of dynamic resistance
commonly prescribed for prevention and exercise include weightlifting, use of a weight
treatment of hypertension machine, push-ups, squats, bicep curls, and
circuit training
They should be performed at least 2-3
times/wk (90-150 min)
Although less well studied, dynamic Common forms of isometric resistance
resistance exercise seems to provide BP exercise include the plank, side bridge, wall
Review of Hypertension Treatment

lowering of similar magnitude to aerobic sit, hand grip, and yoga poses.
exercise and is often used as a complement They should be practiced at least 3-4
to aerobic exercise times/wk
Isometric resistance exercise, also known as
static strength training, involves holding
a position rather than moving.
Although less well studied, it seems to
provide effective BP lowering
Alcohol consumption Epidemiologic studies have repeatedly Interventions have included behavioral Most interventions have aimed for a Reducing or eliminating alcohol
documented a progressive, direct counseling, use of reduced alcohol reduction rather than elimination of alcohol intake results in BP lowering, with an
dose-response relationship between alcohol (eg, light beer) or alcohol-free drinks consumption and have targeted individuals approximately linear dose-response
consumption and level of BP, as well as (eg, mineral water or dealcoholized wine), consuming an average of ≥2-3 alcoholic pattern
prevalence and incidence of hypertension, and abstinence drinks/d, with the goal of consuming ≤2 In a meta-analysis of 31 alcohol
with a doubling of hypertension prevalence standard drinks/d in men and ≤1 standard reduction trials, average SBP/DBP
for individuals consuming ≥3 alcoholic drink/d in women was reduced by 5.5/3.97 mm Hg in
drinks/d compared with people who do not However, any reduction in alcohol individuals consuming ≥2 drinks/d23
drink alcohol22 consumption is beneficial There was no significant reduction in
BP in those drinking <2 alcoholic
beverages/d at baseline
Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; BMI, body mass index Approaches to Stop Hypertension; DBP, diastolic BP; NHANES, National Health and Nutrition Examination Survey;
(calculated as weight in kilograms divided by height in meters squared); BP, blood pressure; DASH, Dietary SBP, systolic BP; USDA, US Department of Agriculture; WHO, World Health Organization.

© 2022 American Medical Association. All rights reserved.

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 Clinical Review & Education Review Review of Hypertension Treatment

Table 2. Recent Randomized Trials of Drug Treatments for Hypertension

SBP/DBP, mm Hga Results

Mean SBP Primary
Source Design Size Sample age, y Baseline targets Achieved outcome Primary outcome results
SPRINT, 2-Arm 9361 Adults with high BP and high 68 140/78 <120 and 119/- and CVD Significant benefit for the
201548 parallel RCT risk of CVD <140 136/- composite primary outcome of composite
and No patients with diabetes or (Median CVD events: 1.65% per year in
202149 survivors of stroke after the intervention group vs 2.19%
Strong representation of older 6 mo) in the standard treatment group
adults and patients with CKD and 25% reduction in all-cause
mortality
STEP,50 2-Arm 9624 Adults 60-80 y with high BP 66 146/82 110-129 CVD Significant 26% benefit in the
2021 parallel RCT High CVD risk cohort and composite primary outcome for intensive
130-149 pharmacologic treatment group
(3.5% vs 4.6%)
Neal Open-label, 20 995 Adults with a history of stroke 65 154/89 NA 151/- Stroke Significant reduction in stroke
et al,31 cluster RCT or ≥60 y with high BP in 600 (Median rates in the salt substitute vs the
2021 villages (clusters) in rural China after 60 regular salt intake group (29.14
Salt substitute (25% potassium mo) events/ 1000 person-years vs
and 75% sodium) vs regular 33.65 events/1000
salt intake person-years)
High CVD risk cohort
ACCORD,51 2 × 2 4733 Adult patients with diabetes 62 139/76 <120 and 119/64 CVD No significant treatment
2010 Factorial who were at high risk for CVD <140 and composite difference (1.87% event rate in
RCT (BP and 133/70 intervention group vs 2.09% in
glycemic control)
interventions) Nominal SPRINT-like benefit for
intensive BP lowering in
normoglycemic subgroup
SPS3,52 2×2 3020 Adults with recent lacunar 63 143/79 <130 and 127/- and Recurrent Nonsignificant lower event rate
2013 Factorial stroke 130-149 138/- stroke (2.25% vs 2.77%, P =.08) in the
RCT (BP and intensively treated group,
antiplatelet compared to control
interventions)
Abbreviations: BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic BP; NA, nonapplicable; RCT, randomized clinical trial;
SBP, systolic BP.
a
Dashes indicate no values were provided for DBP.

of BP, the risk of ASCVD varies approximately 30-fold, depending validated in US Black and White adults. The calculator is accessible on
on the presence of other CVD risk factors.39 For example, at a mean websites46 and may be downloaded as a mobile phone application
SBP of 130 mm Hg, the 10-year predicted risk of ASCVD varies from or embedded in clinical information system software. For antihyper-
1.1% to 38.4%.39 In one of several similar meta-analyses of antihy- tensive drug therapy decisions, a history of a CVD event or a calcu-
pertensive drug treatment trials, a reasonably constant reduction lated 10-year risk of ASCVD at least 10% in adults without a history of
in CVD relative risk (risk ratio of 0.82 to 0.85) has been noted in adults clinical CVD reflects high ASCVD risk and is an indication to prescribe
with different levels of CVD risk at baseline (5-year risk of CVD from antihypertensive drug therapy in adults with stage 1 hypertension.2
<11% to >21%).40 However, the corresponding absolute reduction The knowledge that clinicians may not always formally estimate
in CVD risk was greater in individuals with a higher level of baseline ASCVD risk led the ACC/AHA BP Guideline Writing Committee to ac-
CVD risk compared with a lower one (reduction in CVD events per cept aged 65 years or older, diabetes, and chronic kidney disease as
1000 people over 5 years of 38 vs 14 events). Meta-analyses and surrogate indicators of high ASCVD risk, an approach that was vali-
modeling studies of observational data showed associations of an- dated in an NHANES analysis.47
tihypertensive drugs with improved cardiovascular risk across base-
line SBP from less than 120 mm Hg to at least 170 mm Hg.41 This has
led some researchers to recommend treating adults only according
Pharmacologic Treatment of Hypertension
to high risk of ASCVD42,43 rather than treating individual CVD risk
factors, such as high BP,44 or using population-wide strategies such Table 2 shows the major randomized clinical trials informing this nar-
as sodium intake reduction or smoking cessation.45 The ACC/AHA rative review. Randomized clinical trials have established that phar-
and most other BP guidelines recommend basing treatment deci- macologic BP lowering reduces the risk of CVD events and death in
sions on a combination of ASCVD risk and pretreatment BP level.2 adults with hypertension.6,7 Lowering SBP by 10, 20, or 30 mm Hg
The 2017 ACC/AHA high BP guideline reclassified BP into the fol- to achieve the treatment goal of 120 to 124 mm Hg was associated
lowing categories: normal BP (SBP <120 mm Hg and DBP <80 mm Hg), with a reduction in CVD event rates of 29%, 42%, and 54%,
elevated BP (SBP 120-129 mm Hg and DBP <80 mm Hg), stage 1 hy- respectively.7 For adults with stage 2 hypertension, lifestyle modi-
pertension (SBP 130-139 mm Hg or DBP 80-89 mm Hg), and stage 2 fication combined with antihypertensive drug therapy using 2
hypertension (SBP ⱖ140 mm Hg or DBP ⱖ90 mm Hg).2 For stage 1 complementary agents from different pharmacologic classes is
hypertension, the ACC/AHA BP guideline recommends estimating 10- recommended.2 These patients should be treated regardless of
year ASCVD risk in adults aged 40 to 79 years who have not had a CVD whether they have a history of CVD, and the 2 antihypertensive drugs
event by using the pooled cohort equations calculator, which has been should be combined in 1 pill, if available. For patients with stage 1

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Review of Hypertension Treatment Review Clinical Review & Education

hypertension and either history of CVD or at increased risk for CVD, comitant family history of premature CVD, personal history of hy-
a combination of lifestyle modification and pharmacologic therapy pertension during pregnancy, or history of having been born pre-
with a single drug is recommended. maturely (born significantly before their due date).58
The SBP/DBP goal during antihypertensive therapy in adults First-line pharmacologic therapy for hypertension consists of
younger than 65 years is less than 130/80 mm Hg. Intensive BP con- thiazide diuretics, calcium channel blockers, and angiotensin-
trol in older adults with hypertension has been controversial owing converting enzyme inhibitors or angiotensin receptor blockers
to concerns about adverse consequences of treatment such as or- (Table 3), or available 2-drug combinations. 2,60 Angiotensin-
thostatic hypotension, falls, electrolyte abnormalities, acute kid- converting enzyme inhibitors and angiotensin receptor blockers
ney injury, and hypoperfusion of vital organs, including the heart and should not be administered simultaneously (Table 3).2,60 Unless the
brain. However, in the SPRINT randomized trial, adults aged 75 years patient has a history of ischemic heart disease or heart failure,
or older, even those who were frail or with slow gait, significantly β-blockers are generally not recommended as first-line agents be-
benefited from treatment to an SBP target of less than 120 mm Hg cause of their reduced benefit for stroke prevention compared with
compared with one of less than 140 mm Hg.53 the previously mentioned first-line agents.2,60
The STEP randomized clinical trial of 8511 patients aged 60 to
80 years demonstrated that intensive antihypertensive treatment
to an SBP target of 110 to less than 130 mm Hg reduced CVD events
BP Treatment Target
(stroke, acute coronary syndrome, acute decompensated heart fail-
ure, coronary revascularization, atrial fibrillation, or death from a car- The optimal BP goal for individuals balances the benefits of BP reduc-
diovascular cause) compared with treatment to an SBP target of 130 tion to prevent CVD events with the risks of adverse effects at that
to less than 150 mm Hg.50 After 1 year of treatment, the mean SBP level of BP.2,61 Evidence supporting an SBP goal of less than 130 mm Hg
was 127.5 mm Hg in the intensive treatment group and 135.3 mm Hg for most adults comes from the SPRINT and STEP clinical trials, as well
in the standard treatment group. During a median follow-up period as multiple systematic reviews and meta-analyses.48,49,62-65 Al-
of 3.34 years, primary outcome events occurred in 3.5% of the in- thoughtoourknowledgerecenttrialshavenotfocusedonDBP,avalue
tensive treatment group and 4.6% of the standard treatment group of less than or equal to 80 mm Hg is a reasonable goal and recom-
(hazard ratio for intensive vs standard treatment, 0.74; 95% CI, 0.60- mended as a target for adults younger than 65 years. Thus, the new
0.92; P < .007). This trial was stopped early because of treatment optimal BP goal for adults with hypertension is less than 130/80 mm
benefit. Hypotension, defined as SBP less than 110 mm Hg or DBP Hg except in adults aged 65 years or older when the goal is SBP less
less than 50 mm Hg, was higher in the intensive treatment group than 130 mm Hg without regard to DBP.
compared with the standard treatment group (3.4% vs 2.6%), but For adults with diabetes and hypertension, clinical practice
there were no significant differences in rates of dizziness, syncope, guidelines support an SBP goal of less than 130 mm Hg.2,61,66,67 For
or fractures. There was no difference between the 2 treatment adults with chronic kidney disease who are not undergoing dialy-
groups in rates of estimated glomerular filtration rate decline by 30% sis, with or without diabetes, the most recent Kidney Disease: Im-
or greater or by 50% or greater or the number with an incident es- proving Global Outcomes guidelines recommended an SBP goal of
timated glomerular filtration rate less than 30 mL/min/1.73 m2. less than 120 mm Hg when tolerated,68 but other guidelines rec-
In the SPRINT clinical trial, there were no significant differ- ommend less than 130 mm Hg.2,61 The BP goal for patients with other
ences between the intervention and control groups in rates of or- comorbidities (eg, stroke, ischemic heart disease, peripheral artery
thostatic hypotension (5.7% vs 5.0%), electrolyte abnormalities disease, heart failure) is less than 130/80 mm Hg.2
(2.7% vs 3.7%), injurious falls (6.6% vs 7.5%), or acute kidney in-
jury (2.5% vs 4.3%).54,55 These results were consistent with the 2017 BP Monitoring and Dose Titration to Achieve Target
ACC/AHA BP guideline recommendation of an SBP treatment goal Suboptimal medication adherence and failure by clinicians (ie, phy-
of less than 130 mm Hg for noninstitutionalized ambulatory com- sicians, nurse practitioners, and physician assistants) to appropri-
munity-dwelling adults aged 65 years or older.2 However, titration ately increase medication doses are common causes of not achiev-
to a lower BP goal requires careful monitoring and use of properly ing the BP goal and can prevent optimal reduction in CVD risk and
performed out-of-office or in-office BP measurements to avoid clini- death.69 Successful attainment of the ideal BP level requires con-
cal decision making based on inaccurate, elevated values. tinuous accurate BP monitoring (by patients and their clinicians), ap-
Although randomized clinical trial data are unavailable for young propriate pharmacologic dose titration in response to current BP lev-
adults (18-40 years) with hypertension, recent observational stud- els, and, in those who fail to respond to dose escalation, assessment
ies have demonstrated an association of hypertension with higher of adherence to the antihypertensive regimen.70 Optimally, office-
rates of subclinical CVD in young adults with hypertension, includ- based BP monitoring should be combined with out-of-office mea-
ing in those with a low 10-year ASCVD risk.56,57 For adults with stage surements, such as home BP monitoring recordings obtained by a
1 hypertension, no history of CVD, and a 10-year ASCVD risk less than carefully instructed patient who uses the proper BP measurement
10%, a 6-month trial of intensive lifestyle modification is recom- technique and provides cumulative BP readings to the clinician’s of-
mended. If BP less than 130/80 mm Hg is not attained after approxi- fice. In a study of community-dwelling adults (N = 318), 2 readings
mately 6 months (overall success rate with first attempt, 27%),25 taken in the morning and evening for a minimum of 3 d/wk were suf-
clinicians should consider pharmacologic therapy with a single first- ficient for reliable estimation of out-of-office BP.71 This method not
line antihypertensive agent (ie, diuretic, calcium channel blocker, or only enhances treatment adherence and improves treatment con-
renin-angiotensin system inhibitor).58 Consideration should be given trol but also helps to avoid overtreating white coat hypertension (BP
to earlier initiation of pharmacologic therapy in patients with a con- high in the office but normal at home) and allows detection of

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 Clinical Review & Education Review Review of Hypertension Treatment

Table 3. Major Drug Classes in the Treatment of Hypertension

SBP
Dose range, reduction,
Selected mg, mm Hg57,58 Overall AE
Medication medication (frequency vs placebo Most common rate/class,
class examples per day) Mechanism of action (95% CI) a dverse effects %a Additional comments
First-line
Diuretic Chlorthalidone 12.5-25 Block renal distal tubule Hyponatremia, Chlorthalidone preferred
(thiazide or (once) sodium reabsorption by hypokalemia, (prolonged half-life and
thiazidelike) inhibiting NCC hypercalcemia, proven CVD reduction)
hyperuricemia,
12.4 hyperglycemia, Similar to
(18.8-6.0) dyslipidemia placebo
for diuretics
Hydrochlorothiazide 12.5-50
(once)
Indapamide 1.25-2.5
(once)
ACE inhibitor Benazepril 10-40 (once or Inhibit ACE activity and Hyperkalemia in CKD, Do not use in combination
twice) angiotensin II formation reduced GFR, AKF in with ARB; contraindicated
severe bilateral RAS, in pregnancy
hypotension, cough,
12 angioedema
Enalapril 5-40 (once or (20.5-3.6) Similar to
twice) for ACE placebo
inhibitors
Lisinopril 10-40 (once)
Ramipril 2.5-20 (once)
Trandolapril 1-4 (once)
ARB Azilsartan 40-80 (once) Inhibit angiotensin II Hyperkalemia in CKD, Do not use in combination
binding to the reduced GFR, AKF in with ACE inhibitor;
angiotensin type 1 severe bilateral RAS, contraindicated in
receptor hypotension pregnancy
Candesartan 8-32 (once) 10.7
Similar to
(20.0-1.4)
Losartan 50-100 (once placebo
for ARB class
or twice)
Olmesartan 20-40 (once)
Valsartan 80-320 (once)
CCB Amlodipine 2.5-10 (once) Block voltage-gated Dose-dependent Amlodipine preferred CCB
(dihydropy- (L-type) calcium 15.9 peripheral edema, if tolerated; avoid CCB in
ridine) channels preventing (22.2-9.5) gingival hyperplasia HFrEF
cellular calcium entry for
Felodipine 2.5-10 (once) dihydropy-
ridine class
Nifedipine LA 30-90 (once)
CCB Diltiazem ER 120-360 Block voltage-gated Bradycardia, nausea, Avoid use with β-blocker;
(nondihy- (once) (L-type) calcium 4 (9.1-2.1) constipation do not use in patients with
dropyridine) channels preventing for HFrEF. Contraindicated in
cellular calcium entry nondihy- high-grade AV or SA block
dropyridine
Verapamil 100-300 (once class
delayed-onset ER in evening)
Second-line
MRA Eplerenone 50-100 (twce) Block mineralocorticoid Hyperkalemia, Preferred in low-renin
receptor activity especially in CKD and states and resistant
during potassium hypertension
21.9 supplementation.
(23.0-20.8) Spironolactone:
for MRA gynecomastia and
erectile dysfunction in
men.
Spironolactone 25-100 (once) 8.6-20
β-Blocker Metoprolol Block β-adrenergic 10.1 Asthma, bradycardia, First-line only in IHD and
succinate receptors (14.2-5.1) fatigue, exercise HF; contraindicated in
intolerance, impaired high-grade SA or AV block
concentration and
memory, worsening
depression
Similar to
Carvedilol 50-200 (once) placebo
phosphate
Nebivolol
20-80 (once)
5-40 (once)

(continued)

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Review of Hypertension Treatment Review Clinical Review & Education

Table 3. Major Drug Classes in the Treatment of Hypertension (continued)

SBP
Dose range, reduction,
Selected mg, mm Hg57,58 Overall AE
Medication medication (frequency vs placebo Most common rate/class,
class examples per day) Mechanism of action (95% CI) a dverse effects %a Additional comments
Potassium- Amiloride 5-10 (once or Block cortical collecting NA Hyperkalemia, Minimally effective in BP
sparing twice) duct sodium especially in CKD reduction. Commonly used
Similar to
diuretic reabsorption by to counteract hypokalemia
placebo for
inhibiting ENaC during diuretic use.
potassium-
Triamterene 50-100 (once sparing
or twice) diuretics

Loop diuretic Furosemide 20-80 (twice) Inhibit sodium Volume depletion, Preferred in CKD with GFR
reabsorption in the thick hypokalemia, <30, in symptomatic HF,
ascending limb of the hyperuricemia Similar to and when potent direct
loop of Henle by placebo for vasodilator minoxidil is
inhibiting NKCC2 loop used
Torsemide 5-10 (once) NA diuretics

α1-Antagonist Doxazosin 1-16 (once) Inhibit α1-adrenergic 10.6 Orthostatic 9 Use when increased SNS
receptors (19.8-1.4) hypotension, activity suspected
especially in older
adults
Central Clonidine (oral) 0.1-0.8 Stimulate CNS Sedation, dry mouth, Last line owing to CNS
α2-agonist (twice) α2-adrenergic receptors bradycardia, fatigue, effects and potential for
and other constipation, hypertensive crisis on
centrally orthostatic 6-19 for the withdrawal
acting drugs hypotension drug class
Clonidine patch 0.1-0.3 (1/wk) NA
Guanfacine 0.5-2 (once)
Direct Hydralazine 100-200 Dilate peripheral NA Reflex tachycardia; Hydralazine: use with
vasodilator (2 or 3) arterioles fluid retention diuretic and β-blocker
Minoxidil 5-100 (1-3) Hydralazine: Minoxidil: use with loop
drug-induced lupus Up to 80 for diuretic and β-blocker
syndrome direct
Minoxidil: hirsutism in vasodilators
women
Abbreviations: ACE, angiotensin-converting enzyme inhibitor; AE, adverse MRA, mineralocorticoid receptor antagonist; NA, not available; NCC, sodium
event; AKF, acute kidney failure; ARB, angiotensin receptor blocker; chloride cotransporter; NKCC2, sodium-potassium 2 chloride cotransporter;
AV, atrioventricular; BP, blood pressure; CCB, calcium channel blocker; RAS, renin-angiotensin system; SA, sinoatrial; SBP, systolic BP;
CKD, chronic kidney disease; CNS, central nervous system; CVD, cardiovascular SNS, sympathetic nervous system.
disease; ENaC, epithelial sodium channel; ER, extended release; a
Information obtained from Food and Drug Administration labeling.59
GFR, glomerular filtration rate; HF, heart failure; HFrEF, HF with reduced
ejection fraction; IHD, ischemic heart disease; LA, long acting;

masked hypertension (BP normal in the office but high at home). suggest that initiation of therapy with low-dose combinations may
Upper arm automated cuff measures are generally preferred over be as effective as usual-dose monotherapy in reducing BP.75 Com-
wrist measures for home BP monitoring.72 Direct transmission or pared with shorter-acting diuretics such as hydrochlorothiazide,
electronically entered BP values can facilitate prompt titration of longer-acting agents such as chlorthalidone or indapamide are more
medications in response to home BP measures.73 After initiation of effective for BP lowering and CVD protection.76-79
antihypertensive drug therapy, reassessment at 1 month is indi-
cated and subsequently at 1-month intervals until the BP goal is
achieved, after which follow-up visits should be at 3-month inter-
Resistant Hypertension
vals until BP stability at or below target with minimal to no adverse
effects is accomplished.2 Although in-person follow-up is optimal, Resistant hypertension is defined by lack of adequate BP control dur-
telephone or virtual follow-up may be used when necessary. Once ing treatment with 3 antihypertensive agents of different classes, pre-
control is achieved, the maximal interval between office visits for a scribed at optimal doses and dosing intervals, in patients with good
patient taking antihypertensive medications should be 6 months. adherence.80 Erroneous BP measurement, often caused by failure to
Effective BP control begins with agreement between the clini- use validated devices or by observers who have been inadequately
cian and patient on the BP target. Use of fixed-dose single-pill com- trained or certified for BP measurement, must be excluded before a
binations and 90-day (rather than 30-day) prescription refills re- patient is classified as having resistant hypertension.72,81,82 Simi-
duces complexity, enhances adherence to the antihypertensive larly, the white coat effect, defined as office BP at least 130/80 mm
regimen, and facilitates earlier achievement and maintenance of goal Hg but out-of-office BP less than 130/80 mm Hg, must be ruled out
BP compared with initial monotherapy and subsequent addition of before resistant hypertension is diagnosed.80 Successful BP reduc-
supplemental drugs with the stepped-care approach.74 Recent data tion to goal that requires 4 or more antihypertensive agents indicates

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© 2022 American Medical Association. All rights reserved.

 Clinical Review & Education Review Review of Hypertension Treatment

controlled resistant hypertension.80 Clinicians should evaluate pa- sion education and physician referral alone. In a separate study of
tients with resistant hypertension by probing for poor adherence to 318 Black patients with uncontrolled hypertension in 32 New York
lifestyle and antihypertensive medication practices and use of drugs City churches, a motivational interviewing and lifestyle change cur-
that interfere with antihypertensive medication effectiveness such as riculum delivered by church members compared with a health edu-
nonsteroidal anti-inflammatory agents, oral contraceptives, hor- cation only control group lowered mean SBP by 5.8 mm Hg.92
mone therapy, or glucocorticoids.80 Patients with true resistant hy-
pertension should be screened for secondary hypertension and un-
dergo assessment of target organ damage with a basic metabolic
Organizing and Conducting Team-Based Care
profile (levels of serum sodium, potassium, chloride, bicarbonate, glu-
cose, blood urea nitrogen, and creatinine) and urinalysis.80 If the pa- of Hypertension
tient takes a thiazide diuretic, a long-acting thiazidelike diuretic In team-based hypertension care, a physician coordinates patient care
(chlorthalidone or indapamide) should be used in place of a shorter- with a health care team that may include nurses, pharmacists, life-
acting agent such as hydrochlorothiazide (estimated mean SBP re- style counselors, medical assistants, social workers, community health
duction, 5.6 mm Hg),78 followed by addition of a mineralocorticoid workers, and other clinicians with specialized hypertension training
receptor antagonist (spironolactone or eplerenone) as the fourth drug who are able to contact patients directly and overcome obstacles to
if BP remains uncontrolled.80 If BP remains elevated, stepwise addi- achieving their BP goals. In a meta-analysis of 119 randomized trials
tion of antihypertensive agents with complementary mechanisms of and 920 participants, compared with usual care, team-based hyper-
action, such as a β-blocker or α1-adrenergic antagonist, is indicated, tension care led by trained nonphysician health care professionals was
with consideration of referral to a clinician with expertise in difficult- associated with a mean decrease in SBP of 7.1 mm Hg in patients with
to-control hypertension.80 hypertension, and team-based care increased the proportion of pa-
tients with controlled BP by a median of 8.5%.93,94

Addressing Social Determinants of Health

to Improve BP Control Optimizing Treatment Adherence in Hypertension
In the US, where an estimated 28 million people (8.6%) lack health Pharmacy claims data from the US suggest an antihypertensive medi-
insurance and 1 in 4 do not have access to a primary care clinician,83,84 cine nonadherence rate (defined as proportion of days an individual
it is easy to assume that poor hypertension control nationwide is pri- had prescription medication available <80%) of 31.0%.95 Clinicians
marily due to lack of health insurance or access to health care. How- and health systems can facilitate improved medication adherence.
ever, more than 90% of patients with hypertension have health in- Traditionally, medication adherence has been assessed in clinical
surance and access to a usual source of medical care.85 Lack of health practicebyeitherpatientself-report(ideallyusingastandard,validated
insurance and access to care were not explanations for the re- adherence instrument) or by a count of the number of pills from the
cently reported decline in national hypertension control.85 patient’s pill bottle. Self-report alone has limited accuracy compared
The 2020 US surgeon general’s Call to Action to Control Hyper- with more objective adherence measures. Agreement between a self-
tension recognized that “the conditions in which people are born, reported adherence scale and a criterion standard mass spectrometry
live, learn, work, play, worship, and age directly impact opportuni- assay of urine drug metabolites appears to be very weak (Cohen κ of
ties” to control hypertension in US communities.86,87 In practice, −0.01),96 and self-report scales underpredict nonadherence by 50%
these determinants include not only health care system factors such ormorecomparedwithanobjectivepill-countadherencerecord.97 Be-
as insurance coverage and access to health care and pharmacies but cause objective measures of adherence are more reliable, health sys-
also community factors such as access to safe affordable housing, tems or pharmacies with pharmacy claims databases should use the
healthy foods, quality schools, safe walkable streets, bicycle lanes, timing of prescription refills to objectively measure and provide clini-
gyms, parks, and transportation. Social determinants of health affect cian and patient feedback on medication adherence as the medication
risk of developing hypertension and BP control in people living with possession ratio or proportion of days covered.
hypertension.88,89 In 2382 adults participating in the Multi-Ethnic Adherence support, consisting of interventions such as patient
Study of Atherosclerosis, neighborhood healthy food availability was coaching support and automated reminders, can be delivered to pa-
associated with a 12% lower rate of hypertension (hazard ratio, 0.88; tients who start with limited motivation to treat a chronic, asymptom-
95% CI, 0.82-0.95).90 In a nationally representative sample of US atic condition; those with mental health challenges, cognitive defi-
adults, those with hypertension who did not have a routine place cits, or other comorbid conditions; and those facing financial or social
for health care had a 72% lower prevalence of controlled BP than barriers. Measures implemented at the health system and individual
those who did, and those without insurance had a 34% lower preva- patient levels improve antihypertensive medication adherence.98
lence of controlled BP than those with insurance coverage.88
Hypertension treatment may be more effective and sustain- Limitations
able when delivered at sites near where patients live and con- This Review has several limitations. First, the literature search ex-
ducted in collaboration with community partners trusted by pa- cluded articles not published in English. Second, it may have missed
tients. In a randomized clinical trial of 319 Black male barbershop some relevant publications. Third, not all aspects of hypertension
patrons aged 35 to 79 years from Los Angeles who had uncon- treatment were covered. Fourth, some of the included literature con-
trolled hypertension, a pharmacist-barber collaboration lowered sisted of clinical practice guidelines and scientific statements, which
mean SBP by 21.6 mm Hg91 compared with barber-led hyperten- are based in part on expert opinion.

1858 JAMA November 8, 2022 Volume 328, Number 18 (Reprinted) jama.com

© 2022 American Medical Association. All rights reserved.

Review of Hypertension Treatment Review Clinical Review & Education

style modification, consisting of weight loss, dietary sodium reduc-

Conclusions tion and potassium supplementation, healthy dietary pattern, physi-
cal activity, and limited alcohol consumption. When drug therapy is
Hypertension affects approximately 116 million adults in the US and required, first-line therapies are thiazide or thiazidelike diuretics, an-
more than 1 billion adults worldwide and is a leading cause of CVD giotensin-converting enzyme inhibitors or angiotensin receptor
morbidity and mortality. First-line therapy for hypertension is life- blockers, and calcium channel blockers.

ARTICLE INFORMATION Ann Intern Med. 2015;163(4):245-253. doi:10.7326/ 18. Appel LJ, Moore TJ, Obarzanek E, et al; DASH
Accepted for Publication: October 4, 2022. M14-1753 Collaborative Research Group. A clinical trial of the
6. Ettehad D, Emdin CA, Kiran A, et al. Blood effects of dietary patterns on blood pressure.
Author Contributions: Dr Carey had full access to N Engl J Med. 1997;336(16):1117-1124. doi:10.1056/
all of the data in the study and takes responsibility pressure lowering for prevention of cardiovascular
disease and death: a systematic review and NEJM199704173361601
for the integrity of the data and the accuracy of the
data analysis. meta-analysis. Lancet. 2016;387(10022):957-967. 19. Appel LJ, Champagne CM, Harsha DW, et al;
Concept and design: All authors. doi:10.1016/S0140-6736(15)01225-8 Writing Group of the PREMIER Collaborative
Acquisition, analysis, or interpretation of data: 7. Bundy JD, Li C, Stuchlik P, et al. Systolic blood Research Group. Effects of comprehensive lifestyle
Carey. pressure reduction and risk of cardiovascular modification on blood pressure control: main
Drafting of the manuscript: All authors. disease and mortality: a systematic review and results of the PREMIER clinical trial. JAMA. 2003;
Critical revision of the manuscript for important network meta-analysis. JAMA Cardiol. 2017;2(7): 289(16):2083-2093. doi:10.1001/jama.289.16.2083
intellectual content: All authors. 775-781. doi:10.1001/jamacardio.2017.1421 20. Liu X, Zhang D, Liu Y, et al. Dose-response
Supervision: Carey. 8. Muntner P, Hardy ST, Fine LJ, et al. Trends in association between physical activity and incident
Conflict of Interest Disclosures: Dr Carey reported blood pressure control among US adults with hypertension: a systematic review and
receiving grants from the National Institutes of hypertension: 1999-2000 to 2017-2018. JAMA. meta-analysis of cohort studies. Hypertension.
Health (NIH) during the conduct of this work; 2020;324(12):1190-1200. doi:10.1001/jama.2020. 2017;69(5):813-820. doi:10.1161/
serving as vice chair of the 2017 ACC/AHA High 14545 HYPERTENSIONAHA.116.08994
Blood Pressure Guideline Writing Committee; 9. Poorolajal J, Hooshmand E, Bahrami M, Ameri P. 21. Naci H, Salcher-Konrad M, Dias S, et al.
serving as chair of the AHA Scientific Statement on How much excess weight loss can reduce the risk of How does exercise treatment compare with
Resistant Hypertension; and serving as cochair of hypertension? J Public Health (Oxf). 2017;39(3): antihypertensive medications? a network
the Endocrine Society Clinical Practice Guideline on e95-e102. doi:10.1093/pubmed/fdw077 meta-analysis of 391 randomised controlled trials
Primary Aldosteronism Panel. Dr Whelton reported assessing exercise and medication effects on
serving as chair of the SPRINT Steering Committee 10. Fryar CD, Carroll MD, Afful J. Prevalence of systolic blood pressure. Br J Sports Med. 2019;53
and the 2017 ACC/AHA High Blood Pressure overweight, obesity and severe obesity among (14):859-869. doi:10.1136/bjsports-2018-099921
Guideline Writing Committee and reported adults aged 20 and over: United States, 1960-1962
through 2017-2018: NCHS Health E-Stats. 2020. 22. Klatsky AL, Gunderson E. Alcohol and
receiving grants from the National Institutes of hypertension: a review. J Am Soc Hypertens. 2008;
Health. Dr Moran reported receiving grants from Accessed January 15, 2022. https://www.cdc.gov/
nchs/nhanes/analyticguidelines.aspx 2(5):307-317. doi:10.1016/j.jash.2008.03.010
the National Institutes of Health. No other
disclosures were reported. 11. Neter JE, Stam BE, Kok FJ, Grobbee DE, 23. Roerecke M, Kaczorowski J, Tobe SW, Gmel G,
Geleijnse JM. Influence of weight reduction on Hasan OSM, Rehm J. The effect of a reduction in
Submissions: We encourage authors to submit alcohol consumption on blood pressure:
papers for consideration as a Review. Please blood pressure: a meta-analysis of randomized
controlled trials. Hypertension. 2003;42(5):878-884. a systematic review and meta-analysis. Lancet
contact Mary McGrae McDermott, MD, at Public Health. 2017;2(2):e108-e120. doi:10.1016/
[email protected]. doi:10.1161/01.HYP.0000094221.86888.AE
S2468-2667(17)30003-8
12. Zhang Z, Cogswell ME, Gillespie C, et al.
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