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Low-dose double combinationa therapy ACEi or ARBs / CCBs / Diuretics

(Class I)

BP controlled after 1–3 months (assessment at 1 month preferred if possible)

Y FU at least every year

Low-dose triple combination therapy ACEi or ARBs / CCBs / Diuretics

(Class I)

BP controlled after 1–3 months (assessment at 1 month preferred if possible)

Y FU at least every year

BP controlled after 1–3 months (assessment at 1 month preferred if possible)

Y FU at least every year

Refer to hypertension clinic

(Class IIa) At any step: add beta-blockers if compelling indications (angina, post-myocardial infarction, systolic heart failure,

or heart rate control)

(Class I)

Maximally tolerated triple combination therapy ACEi or ARBs / CCBs / Diuretics

(Class I)

Test for adherence

(Class IIa)

Add spironolactone

(Class IIa)

Apparent resistant hypertension

N

N

N

aInitial monotherapy preferred

Elevated BP category (120/70–139/89 mmHg) Moderate-to-severe frailty Symptomatic orthostatic hypotension Age ≥85 years

See section on management of resistant hypertension for further steps as needed

Figure 18 Practical algorithm for pharmacological blood pressure lowering. ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; FU, follow-up. Downloaded from academic.oup.com/eurheartj/article/45/38/3912/7741010 by guest on 07 October 2026