weight by eating a healthy diet or increasing physical activity, doing both is most effective. See the Adult Weight Management Screening and Intervention Guideline for recommendations and further information. Diet Patients with hypertension should be advised to reduce their dietary sodium intake to no more than 2,400 mg per day; further reduction to 1,500 mg/day is desirable as it leads to even greater decreases in BP. If the desired sodium level is not achieved, consider an alternative goal of reducing current sodium intake by 1,000 mg/day. Additionally, all patients should strive to: · Make smart choices from every food group to meet their caloric needs. · Get the most and best nutrition from the calories consumed. The DASH eating plan provides the following key elements: an abundance of plant foods (fruits, vegetables, whole-grain breads or other forms of cereals, beans, nuts, and seeds), minimally processed foods, lean meats, poultry, and fish, and seasonally fresh foods. Use the AVS SmartPhrases .avsdash and .avsnutrition. Physical activity Advise adults to engage in aerobic physical activity 3 to 4 sessions per week. Each session should be of moderate-to-vigorous intensity and last an average of 40 minutes. For patients who have been inactive for a while, recommend starting slowly and working up, at a comfortable pace, to at least 30 minutes per day. If a patient is unable to be active for 30 minutes at one time, suggest accumulating activity over the course of the day in 10- to 15-minute sessions. Moderation of alcohol consumption Because alcohol use can raise blood pressure, patients with hypertension should use alcohol in moderation, if at all. Screen patients using the AUDIT-C Alcohol Questionnaire, and provide brief guidance when appropriate. See the Adult Unhealthy Drinking Screening and Intervention Guideline for more detailed recommendations. 7 Pharmacologic Options Table 4. Initial antihypertensive medication recommendations by patient subgroup Note: A suggested default pathway for medication treatment is on p. 8. Patient subgroup Drug class for initial therapy (Bold type indicates a preferred drug class. See also “Prescribing notes” following this table.) General population Alone or in combination: ACE inhibitor (or ARB if intolerant) Thiazide diuretic Calcium channel blocker Chronic kidney disease (CKD) Alone or in combination: ACE inhibitor (or ARB if intolerant) Thiazide diuretic Calcium channel blocker Diabetes Alone or in combination: ACE inhibitor (or ARB if intolerant) Thiazide diuretic Calcium channel blocker Atherosclerotic cardiovascular disease (ASCVD) Alone or in combination: ACE inhibitor (or ARB if intolerant) Beta-blocker (preferred for patients with recent angina or myocardial infarction) Thiazide diuretic Calcium channel blocker Congestive heart failure (CHF) Treat per standard CHF guidelines. Given the blood pressure– lowering effect of many first-line CHF medications, it is rarely necessary to add medications specifically for the hypertension. Consult Cardiology if questions. Prescribing notes: Table 4 ACE inhibitors and ARBs · ACE inhibitors and ARBs should not be used in combination. · ACE inhibitors and ARBs are somewhat less efficacious in black patients, and therefore are not a preferred first-line choice for blacks, unless they have a clinical condition where these medications are recommended (e.g., CKD, diabetes, ASCVD). · ACE inhibitors and ARBs are teratogenic. If a patient is pregnant or anticipating pregnancy, consider consultation with Obstetrics for BP management. · ACE inhibitors should generally be chosen first-line above ARBs. ACE inhibitors are less expensive, and while some studies show similar clinical outcomes, others still show ACE inhibitors as superior. However, if a dry, persistent cough develops (normally within about 2 weeks, but potentially at up to 6 months) and appears to be caused by the ACE inhibitor, consider switching directly to an ARB. In a meta-analysis of 125 studies, the pooled incidence of ACE inhibitor–induced cough was reported to be 10.6% (Bangalore 2010). Beta-blockers · Beta-blockers are no longer a first-line recommendation for hypertension unless the patient has a comorbidity for which beta-blockers are preferred (e.g., angina, recent myocardial infarction, systolic heart failure, atrial fibrillation, or thoracic aneurysm). Consider beta-blockers if blood pressure has still not been controlled with the medications in Table 4. · If the patient is already on beta-blockers for hypertension, use shared decision making to consider whether to continue with beta-blockers or switch to one of the preferred classes. 8 Consultative specialty service referral Patients should be referred to consultative specialty services in the following situations: · Blood pressure remains uncontrolled despite aggressive therapy with a minimum trial of 3 or 4 medications listed in Table 4. · The patient has shown a dramatic failure to respond to medications. · The patient is under age 25 years. Refer patients to: · Consultative Internal Medicine, unless there is a clear element of renal failure. · Nephrology if there is a clear element of renal failure (creatinine > 2 mg/dL or rising creatinine with proteinuria). · Cardiology only if the patient is currently under the active management of a cardiologist. The following workup should be ordered and completed prior to the patient being seen by the consultative