VA/DoD Clinical Practice Guideline: Diagnosis and Management of Hypertension (HTN) in Primary Care

I. Introduction

The Department of Veterans Affairs (VA) and Department of Defense (DOD) Evidence-Based Practice Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the “…Health Executive Council (HEC) on the use of clinical and epidemiological evidence to improve the health of the population across the Veterans Health Administration (VHA) and Military Health System (MHS),” by facilitating the development of clinical practice guidelines (CPGs) for the VA and DOD populations.(1) The development and updating of VA/DOD CPGs is funded by VA Evidence Based Practice, Office of Quality and Patient Safety. The system wide goal of evidence-based guidelines, this CPG, is to guide providers in hypertension management in addition to offering management pathways supported by evidence. This CPG is intended to provide health care providers with a practical framework by which to evaluate, treat, and manage hypertension, address the individual needs and preferences of patients, and improve clinical outcomes.

In 2020, the VA and DOD published an updated CPG for the Diagnosis and Treatment of Hypertension (HTN) in Primary Care (2020 VA/DOD Hypertension CPG), which was based on evidence reviewed from December 15, 2013, through March 25, 2019. Since then, a growing body of research has expanded the general knowledge and understanding of the diagnosis and treatment of hypertension. Consequently, a recommendation to update the 2020 VA/DOD Hypertension CPG was initiated in July 2025 using published data from March 1, 2019, through November 12, 2025. This updated CPG’s use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach reflects a more rigorous application of the methodology than previous iterations.(2) Therefore, the strength of some recommendations might have been modified because of changes in the quality of the supporting evidence (see Evidence Quality and Recommendation Strength).

This CPG provides an evidence-based framework for evaluating and managing adult patients with hypertension who are eligible for care in the VA or DOD systems, including community care. Successful implementation of this CPG will:

• Emphasize the use of patient-centered care using risk factors and event history;
• Minimize preventable complications and morbidity;
• Optimize each patient’s health outcomes and improve quality of life; and
• Assess the patient’s condition and in collaboration with the patient, family, and caregivers, determine optimal treatment.

II. Background

A. Epidemiology and Impact on the General Population

Blood pressure (BP) is a continuous variable that can increase with advancing age. Elevated blood pressure along with elevated cholesterol, tobacco use, and diabetes, is an established risk factor for conditions like coronary artery disease (CAD), heart failure, stroke, peripheral vascular disease, chronic kidney disease (CKD) and cognitive decline. Also, conditions like CKD and/or diabetes can elevate hypertensive risk. Increases in blood pressure have been shown to have a continuous, graded positive association with atherosclerotic cardiovascular disease (3), and are positively associated with fatal and non-fatal vascular and nonvascular events.(4) Hypertension, or pathologically elevated blood pressure, is a silent asymptomatic condition, which is considered a modifiable risk factor for cardiovascular disease (CVD). CVD has plagued the United States (US) as one of the most common causes of death since the 1900s.(5,6) In 2023, one in every three deaths was associated with CVD.(7) The prevalence of hypertension varies by age, sex, and ethnicity.(8) Blood pressure progressively increases with advancing age; almost half of the elderly population has hypertension, with rates higher in men (50.8%) than women (44.6%).(9) Hypertension develops at a younger age in individuals who are non-Hispanic Black, and may present with a higher prevalence of complications at the time of diagnosis, including stroke and end-stage kidney disease, when compared with other ethnic groups.(10) Jaeger et al. (2023) noted that between 2017 and 2020, a higher percentage of US adults with hypertension compared to those without were non-Hispanic Black (13.5% vs. 9.3%), while a lower percentage of those with hypertension compared to those without were Hispanic (12.3% vs.18.1%).(11) Martin et al. (2024)(8) found that more than half (50.4%) of US males and 43% of females ≥ 20 years of age have hypertension, mirroring the prevalence of CVD, which remains highest among non- Hispanic Black females (59%) and non-Hispanic Black males (58.9%), findings supported by Jaeger et al. (2023).(11)

The definition of hypertension has evolved over the past five decades as clinical trials have progressively lowered the level of blood pressure at which the benefits of treatment outweigh the risks. In 2017, the American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults redefined hypertension by lowering the threshold levels of 140/90 millimeters of mercury (mmHg) to 130/80 mmHg.(11) Based on data from the National Health and Nutrition Examination Survey (NHANES), which studied 56,017 participants between 2017 and 2020, it is estimated that 115.3 million Americans have hypertension defined by the 2017 ACC/AHA BP guideline, systolic blood pressure (SBP) of 130 mmHg or higher or a diastolic blood pressure (DBP) of 80 mmHg or higher.(12,13) The asymptomatic nature of hypertension can make detection challenging; therefore, routine screening is paramount. Furthermore, the asymptomatic nature of hypertension can lead to challenges with adherence to treatment. In the US general population, hypertension control rates have decreased from 53.8% controlled (2013-2014) to 43.7% controlled (2017- 2018).(14) It was lowest for Hispanic (36.8%), followed by non-Hispanic Black (38.5%) and non- Hispanic Asian individuals (43.4%). Among US Veterans, hypertension control rates varied across sectors by race and ethnicity (range, 44.1%–97.5%); Black Veterans, followed by American Indian or Alaska Native Veterans, had the lowest mean control rates.(15) There was also significant geographical variance among poorly controlled hypertension control rates.(15) Advances in science and technology have helped drive a decline in mortality; however, clinicians still need to evolve their practice and remain engaged with their patients as they continue to help improve modifiable risk factors in their patients. In this CPG, the Work Group specifically investigated the point of proven benefit for hypertension treatment (see Recommendations 4-6); based on this evidence, the Work Group defines hypertension as SBP and/or DBP at or above 130/90 mmHg, assuming proper measurement technique.

B. Hypertension in the Department of Veterans Affairs and Department of Defense Populations

Estimates of HTN prevalence among active-duty military are limited and undoubtedly skewed by policies that limit recruitment of individuals who already have cardiovascular risk factors such as HTN, obesity, and diabetes. Survey data report an overall prevalence of 9.1% in the active-duty population, with higher rates in men and more senior pay grades.(16) Compared to active-duty military who have not deployed, exposure to multiple stressful deployments was associated with a new diagnosis of HTN.(17) In the first study to directly compare cardiovascular health metrics of active-duty Army men and women with those of NHANES participants evaluated between 2011 and 2012, NHANES participants had a higher prevalence of ideal blood pressure defined as <120/80 mmHg (46% versus 27% for men, 63% versus 52% for women) compared to active-duty Army personnel, even though NHANES participants were considerably older than the Army personnel (only 50% of NHANES participants <40 years old).(18)

Applying the AHA and ACC definition of HTN as a systolic blood pressure of ≥130 mmHg or a diastolic blood pressure ≥80 mmHg (11), the prevalence of HTN among Veterans was 48.2% in fiscal years 2016-2019.(19) This prevalence closely aligns with the 48.1% prevalence reported for the US general population, based on NHANES data from 2017 to 2020.(20) Similar to the general population, the prevalence of HTN among Veterans increases with age, ranging from 10.7% among individuals 18-44 years to 62.7% among those aged 65 years and older. Male Veterans had a higher prevalence of HTN (50.1%) compared to female Veterans (27.3%). Among racial and ethnic groups, the prevalence was highest among Black Veterans (54.2%), followed by White (49.5%), Native Hawaiian or Other Pacific Islanders (47.4%), Hispanic (39.6%), and Asian (36.5%).(21) Blood pressure control rates, defined by a treatment goal of <140/90 mmHg among patients aged 45-64, were 76.6% for female and 75% for male Veterans in fiscal years 2016- 2019. These control rates are higher than those reported in the general population (40.5%).(20) However, among all Veterans, younger Veterans and those with diabetes or residing in rural areas had lower rates of blood pressure control.(19) This CPG on the management of HTN in the primary care setting is intended to promote evidence-based management of HTN and thereby improve patients’ clinical outcomes. It can assist primary care providers in the screening and diagnosis of HTN, determination of appropriate treatment, and delivery of individualized interventions. Although it was developed for a broad range of clinical settings, it should be applied with enough flexibility to accommodate local practice and individual situations.

C. Hypertension Impact on Readiness in the Military

Hypertension poses a direct threat to military readiness, impairing Service members’ health, performance, and overall operational readiness, as well as increasing risk for cardiovascular events. Hypertension is common in the DOD, with survey data from 2018 reporting that 9.1% of the active-duty population carried a hypertension diagnosis.(16) Evidence suggests that hypertension is underdiagnosed and undertreated in the military population, potentially increasing the risk of short-term impact on readiness and long-term adverse cardiovascular consequences.(18,22) Risk factors for developing hypertension, such as obstructive sleep apnea (23), tobacco use (16), and non-regulated supplement use (24) may be more common in the active-duty population compared to the general population in the United States. Furthermore, common military exposures, such as combat, sleep deprivation, and traumatic experiences resulting in chronic post-traumatic stress disorder (PTSD) all increase the risk of hypertension.(17,25-27)

The proper diagnosis of hypertension is critical in the active-duty population. Consideration of white coat effect and white coat hypertension are important, as a new diagnosis could adversely impact duty status and unit readiness, while proper measurement of blood pressure may be challenging in operational clinical environments. Improper measurement can lead to both over and underdiagnosis.

The immediate impact on readiness for Service members with hypertension depends on many factors, such as the degree of blood pressure elevation, the Service member’s occupation or special duty, the timeline and location of the deployment, and the availability of medical resources while deployed. The diagnosis of hypertension is not immediately disqualifying for most duties, but certain special communities, such as aviation, have specific requirements for the assessment, management, and control of hypertension. In general, a Service member with significantly elevated blood pressure is unlikely to be fully medically ready or world-wide deployable, regardless of occupation. Mild elevations in blood pressure will restrict Service members in special populations from achieving full medical readiness. One study (28) found a six-fold increase in the prevalence of hypertension in Naval aviators with application of the more stringent hypertension diagnostic criteria from the 2017 ACC/AHA guidelines (29) compared to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) Guidelines, with up to 45% of Naval aviators potentially having the diagnosis of hypertension. Blood pressure control is seldom achieved rapidly as titration of therapy over months is often required, which may restrict a Service member from full readiness and deployability for an extended period. Furthermore, some medications may be restricted or limited in special populations (such as beta blockers in aviation). Other first-line medications may be challenging to initiate and titrate in austere environments (such as diuretics in heat environments), when routine laboratory monitoring is not available, or when side effects of therapy could jeopardize the Service member’s health and adversely affect the mission.

Most active-duty Service members can be fully medically ready and deployable world-wide with the diagnosis of hypertension if the diagnosis is made and management is initiated and managed in accordance with this CPG. In addition to the long-term health benefits, early and optimal treatment of hypertension can ensure blood pressure does not impact Service members’ readiness.

III. Scope of This Guideline

This CPG is based on published clinical evidence and related information available between March 1, 2019, and November 12, 2025. It is intended to provide general guidance on best evidence-based practices (see Appendix A for additional information on the evidence review methodology). Although the CPG is intended to improve the quality of care and clinical outcomes (see Introduction), it is not intended to define a standard of care (i.e., mandated or strictly required care).

A. Guideline Audience

This CPG is intended for use by providers who manage, co-manage, or otherwise care for adults with hypertension.

B. Guideline Population

This CPG is intended for adults (18 years or older) with hypertension who are eligible for care in the VA or DOD systems, including community care.

IV. Highlighted Features of This Guideline

A. Highlights in this Guideline Update

This document is an update to the 2020 VA/DOD Hypertension CPG. A major strength of this CPG is the coordination and collaboration of a multidisciplinary team, ensuring broad representation of providers engaged in hypertension treatment and management. The framework for recommendations in this CPG considered factors beyond the strength of the evidence, including balancing desired outcomes with potential harms of the intervention, the potential for variation in patient values and preferences, the unique needs of the VA/DOD populations, and other considerations (e.g., resource use, subgroup considerations) as appropriate.

The following significant updates highlight the importance of reviewing this version of the CPG:

• Four new recommendations were added • Five recommendations were reviewed and replaced • Eight recommendations were reviewed and amended • Two recommendations were reviewed and carried over without changes • Two recommendations were carried over without review or changes from previous CPG • Two recommendations were deleted as they represent current best practice and did not need to be highlighted as specific recommendations • The Algorithm and Sidebars were updated to reflect current evidence and practice

The following updates may change clinical practice:

• Treating hypertension to a target systolic blood pressure of <130 mmHg is recommended, individualized by patient characteristics and preferences. • There is insufficient evidence to recommend treating to a target diastolic blood pressure of <80 mmHg versus <90 mmHg. • Using glucagon-like peptide-1 (GLP-1) receptor agonist-based medications for weight loss and blood pressure reduction in patients with hypertension and overweight/obesity is recommended.

B. Components of this Guideline

This CPG provides clinical practice recommendations for patients who would benefit from hypertension diagnosis and/or management (see Recommendations). In addition, the Algorithm integrates the recommendations in the context of the flow of patient care. This CPG also includes Research Priorities, which list areas the Work Group identified as needing additional research. To accompany this CPG, the Work Group also developed toolkit materials for providers and patients, including a provider summary, patient summary, and a quick reference guide, which can be found at https://www.healthquality.va.gov/index.asp.

C. Demographic Terminology in This Guideline

The demographic terms used in this guideline are derived from the published literature sources included in the systematic review (SR) and evidence base. The Work Group used terms such as Black rather than African American, and White rather than Caucasian to avoid presumptions about ancestry and improve clarity and consistency. In order to accurately present the research evidence on which this CPG is based, the Work Group made every effort to use the same terminology as reported in the published literature base of systematic reviews, clinical trials, and other studies. Consequently, usage of demographic terms in this CPG may vary and appear inconsistent.

V. Guideline Development Team

The VA Evidence Based Practice, Office of Quality and Patient Safety, in collaboration with the Clinical Quality Improvement Program, Defense Health Agency, identified the following four providers to serve as Champions (i.e., leaders) of this CPG’s Work Group: Addison Taylor, MD, PhD, Elvira Gosmanova, MD and Peter Glassman, MBBS, MSc from VA; and Mark Tschanz, DO and Patricia Vu, MD, PhD, MPH from DOD. The Work Group was comprised of individuals with the following areas of expertise: primary care, cardiology, pharmacy, physical therapy, public health, nursing, dietary sciences, and nephrology. Table 1 lists the Work Group and Guideline Development Team members.

This CPG Work Group, led by the Champions, was tasked with:

• Determining the scope of the CPG;
• Crafting clinically relevant key questions (KQs) to guide the systematic evidence review;
• Identifying discussion topics for the patient focus group and considering the patient perspective;
• Providing direction on inclusion and exclusion criteria for the systematic evidence review and the assessment of the level and quality of evidence; and
• Developing evidence-based clinical practice recommendations, including determining the strength and category of each recommendation.

Sigma Health Consulting and Duty First Consulting were contracted by the VA to help develop this CPG.

Table 1. Guideline Work Group and Guideline Development Team

*Additional contributor contact information is available in Appendix D

VI. Summary of Guideline Development Methodology

The methodology used in developing this CPG follows the Guideline for Guidelines, an internal document of the VA/DOD EBPWG updated in January 2019 that outlines procedures for developing and submitting VA/DOD CPGs.(30) The Guideline for Guidelines is available at http://www.healthquality.va.gov/policy/index.asp. This CPG also aligns with the National Academy of Medicine’s (NAM) principles of trustworthy CPGs (e.g., explanation of evidence quality and strength, management of potential conflicts of interest [COI], interdisciplinary stakeholder involvement, use of SR and external review).(31) Appendix A provides a detailed description of the CPG development methodology.

A. Evidence Quality and Recommendation Strength

The Work Group used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to craft each recommendation and determine its strength. Per the GRADE approach, recommendations must be evidence-based and cannot be made based on expert opinion alone. The GRADE approach uses the following four domains to inform the strength of each recommendation (see Determining Recommendation Strength and Direction)(32):

1. Balance of desirable and undesirable outcomes

2. Confidence in the quality of the evidence

3. Patient or provider values and preferences

4. Other implications, as appropriate (e.g., resource use, equity, acceptability, feasibility, subgroup considerations)

Using these four domains, the Work Group determined the relative strength of each recommendation (Strong or Weak). 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 incorporates the four domains.(33) A Strong recommendation generally indicates High or Moderate confidence in the quality of the available evidence, a clear difference in magnitude between the benefits and harms of an intervention, similar patient values and preferences, and understood influence of other implications (e.g., resource use, feasibility). A recommendation’s strength (i.e., Strong versus Weak) does not reference its clinical importance (e.g., a Weak recommendation is evidence-based and still important to clinical care).

In some instances, the systematic evidence review might have found little or no relevant evidence, inconclusive evidence, or conflicting evidence for a particular therapy or intervention. The way this finding is expressed in the CPG might vary. The Work Group might include a statement among its recommendations acknowledging insufficient evidence for or against a commonly practiced intervention, particularly if it lacks supporting clinical evidence and poses potential risks (e.g., high opportunity cost, misallocation of resources). In other cases, the Work Group might choose to remain silent in cases where evidence is lacking for a rarely used intervention or when an intervention, despite the absence of recent evidence, is considered the standard of care and has a favorable balance of benefits and harms.

Using these elements, the Work Group determines the strength and direction of each recommendation and formulates the recommendation with the general corresponding text as shown in Table 2.

Table 2. Strength and Direction of Recommendations and General Corresponding Text

This CPG’s use of GRADE reflects a more rigorous application of the methodology than previous iterations; the determination of the strength of the recommendation is more directly linked to the confidence in the quality of the evidence on outcomes that are critical to clinical decision-making. The confidence in the quality of the evidence is assessed using an objective, systematic approach independent of the clinical topic of interest. Therefore, recommendations on topics for which designing and conducting rigorous studies (e.g., randomized controlled trials [RCTs]), might be inherently more difficult, are typically considered lower quality evidence and, in turn, are usually Weak recommendations. Recommendations on topics for which rigorous studies can be designed and conducted (e.g., RCTs) may more often be Strong recommendations. Per GRADE, if the quality of evidence differs across the relevant critical outcomes, the lowest quality of evidence for any of the critical outcomes determines the overall quality of the evidence for a recommendation.(2,34) This stricter standard provides a consistent approach to determining recommendation strengths. For additional information on GRADE or CPG methodology, see Appendix A.

B. Categorization of Clinical Practice Guideline Recommendations

Evidence-based CPGs should be current. Except for an original version of a new CPG, staying current typically requires revision of a CPG’s previous versions based on new evidence or as scheduled subject to time-based expirations.(35) For example, the U.S. Preventative Services Task Force (USPSTF) has a process for monitoring the emergence of new evidence that could prompt an update of its recommendations, and it aims to review each topic at least every five years for either an update or reaffirmation.(36)

Recommendation categories are used to track how the previous CPG’s recommendations could be reconciled. These categories and their corresponding definitions are similar to those used by the National Institute for Health and Care Excellence (NICE, England).(37,38) Table 3 lists these categories, which are based on whether the evidence supporting a recommendation was systematically reviewed, the degree to which the previous CPG’s recommendation was modified, and whether a previous CPG’s recommendation is relevant in the updated CPG.

Additional information regarding these categories and their definitions can be found in Recommendation Categorization. The 2026 VA/DOD Hypertension CPG recommendation categories can be found in Recommendations. Appendix B outlines the 2026 VA/DOD Hypertension CPG’s recommendation categories.

Table 3. Recommendation Categories and Definitions*

*Adapted from the NICE guideline manual (2012)(38) and Garcia, et al. (2014)(37) Abbreviations: CPG: clinical practice guideline

C. Management of Potential or Actual Conflicts of Interest

Management of COIs for the CPGs is conducted as described in the Guideline for Guidelines.(30) Further, the Guideline for Guidelines refers to details in the VHA Handbook 1004.07 Financial Relationships between VHA Health Care Professionals and Industry (November 2014, issued by the VHA National Center for Ethics in Health Care)(39) as well as to disclosure statements (i.e., standard disclosure form completed at least twice by CPG Work Group members and the guideline development team).(30) The disclosure form inquires about relevant financial and intellectual interests or other relationships with, for example, manufacturers of commercial products, providers of commercial services, or other commercial interests. The disclosure form also inquires about any other relationships or activities that could be perceived to have influenced, or give the appearance of potentially influencing, a respondent’s contributions to the CPG. In addition, instances of potential or actual COIs among the CPG Work Group and the guideline development team were subject to random web-based identification via standard electronic means (e.g., Centers for Medicare & Medicaid Services Open Payments, ProPublica).

D. Patient Perspective

When developing a CPG, consideration should be given to patient perspectives and experiences, which often differ from those of providers.(34) Focus groups can be used to help collect qualitative data on patient perspectives and experiences. VA and DOD Leadership arranged a virtual patient focus group on September 26, 2025. The focus group aimed to gain insights into the perspectives of individuals who received care in the VA and DOD healthcare systems for hypertension and incorporated these insights into the CPG, as appropriate. Topics discussed included various treatments they have used as well as medication side effects, their desire for continuity of care, the importance of accurate screening and early diagnosis, and the value of whole-person approaches.

The patient focus group was comprised of a convenience sample of seven participants, which included one woman and six men. Participants were mixed in terms of receiving care from the VA and DOD, and one participant also received some care from civilian providers. Participants’ length of hypertension treatment ranged widely from as recent as two years to as long as 30 years. The Work Group acknowledges that this convenience sample is not representative of all individuals who have undergone hypertension treatment within the VA and DOD healthcare systems, and thus, findings are not generalizable and do not comprise evidence. For more information on the patient focus group methods and findings, see Appendix E. Patient focus group participants were provided with the opportunity to review the final draft of this CPG and share additional feedback.

E. External Peer Review

The Work Group drafted, reviewed, and edited this CPG using an iterative process. For more information, see Drafting and Finalizing the Guideline. Once the Work Group members completed a near-final draft, they identified individuals from VA and DOD health care systems and external organizations generally viewed as experts in their respective fields. The draft was sent to those experts for a 14-business-day review and comment period. The Work Group considered all feedback from the peer reviewers and modified the CPG where justified, in accordance with the evidence. Detailed information on the external peer review may be provided by the VA Office of Quality and Patient Safety.

F. Implementation

This CPG and algorithm are designed for adaptation by individual health care providers with respect to unique patient considerations and preferences, local needs, and resources. The algorithms serve as a tool to prompt providers to consider key decision points in the care of patients who would benefit from hypertension treatment and management. The Work Group submits suggested performance metrics for VA and DOD to use when assessing the implementation of this CPG. Robust implementation is identified in VA and DOD internal implementation plans and policies. Additionally, implementation will entail wide dissemination through publication in the medical literature, online access to the final CPG, educational programs, and ideally, electronic medical record programming in the form of clinical decision support tools at the point-of-care.

VII. Approach to Care in the Department of Veterans Affairs and the Department of Defense

A. Patient-Centered Care

VA and DOD encourage providers to be sensitive to demographic, cultural, and other differences that affect patients’ values, needs, and preferences. Patient-centered care is aimed at treating the condition while also optimizing the individual’s overall health and well-being. Regardless of the care setting, all patients should have access to individualized evidence-based care. Patient- centered care can decrease patient anxiety, increase trust in providers, and improve treatment adherence.(40,41) A holistic health approach (https:/www.va.gov/wholehealth/) empowers and equips individuals to meet their personal health and well-being goals. Good communication is essential and should be supported by evidence-based information tailored to each patient’s needs. Guideline recommendations should be applied in a holistic approach to care that is patient- centered, culturally appropriate, and available to people with limited literacy skills and physical, sensory, or learning disabilities. The focus is using an individual’s risk factors and event history to guide the various treatment and management strategies for patients with hypertension.

B. Shared Decision-Making

This CPG encourages providers to practice shared decision making (SDM), a process in which providers, patients, and patient care partners (e.g., family, friends, caregivers) consider clinical evidence of benefits and risks as well as patient values and preferences to make decisions regarding the patient’s treatment.(42) SDM is emphasized in “Crossing the Quality Chasm”, an Institute of Medicine, now NAM, report in 2001 (43) and is a core component of a patient- centered, whole health approach. Providers must be adept at presenting information to their patients regarding individual treatments, expected risks, possible outcomes, and levels and/or settings of care, especially where patient heterogeneity in weighing risks and benefits might exist. The VA and DOD have embraced SDM. Providers are encouraged to use SDM to individualize treatment goals and plans based on patient capabilities, needs, values, and preferences.

C. Patients with Co-occurring Conditions

Co-occurring conditions can modify the degree of risk, impact diagnosis, influence patient and provider treatment priorities and clinical decisions, and affect the overall approach to hypertension treatment and management. Many Veterans, active-duty Service members, and their families have one or more co-occurring conditions. Because hypertension is often accompanied by co- occurring conditions, collaborative management with other care providers is often best. Some co- occurring conditions may require early specialist consultation to determine necessary changes in treatment or establish a common understanding of how care should be coordinated.

VA/DOD Clinical Practice Guideline for Diagnosis and Treatment of Hypertension in Primary Care

VIII. Algorithm

This CPG’s algorithm is designed to facilitate understanding of the clinical pathway and decision- making process used in the diagnosis and management of hypertension. The algorithm format represents a simplified flow of the management of hypertension, helping to foster efficient decision-making by providers. It includes:

• An ordered sequence of steps of care
• Recommended observations and examinations
• Decisions to be considered
• Actions to be taken

The algorithm is a step-by-step decision tree. Standardized symbols are used to display each step, and arrows connect the numbered boxes indicating the order in which the steps should be followed.(44) Sidebars provide more detailed information to assist in defining and interpreting elements in the boxes.

Module A. Screening and Diagnosis

Algorithm or figure on page 19 of the original PDF is not reproduced here — see the original document (text descriptions of the algorithms are in the appendix, if provided).

Module B. Treatment

Algorithm or figure on page 20 of the original PDF is not reproduced here — see the original document (text descriptions of the algorithms are in the appendix, if provided).

Abbreviations: AOBP – automated office blood pressure; BP – blood pressure; CPG – clinical practice guideline; HTN – hypertension

Abbreviations: mmHg – millimeters of mercury

Abbreviations: ACEI – angiotensin-converting enzyme inhibitor; ARB – angiotensin II receptor blocker; CCB – calcium channel blocker; CKD – chronic kidney disease; DBP – diastolic blood pressure; HTN – hypertension; mmHg – millimeters of mercury; SBP – systolic blood pressure

Abbreviations: HTN – hypertension; NSAID – nonsteroidal anti-inflammatory drug

*Greater reduction seen in patients with a higher baseline BP.

**Adding an agent from a different pharmaceutical class offers significantly greater blood pressure reduction and often better tolerability compared to simply increasing the dose of a single monotherapy agent. While doubling the dose of a monotherapy typically yields only an additional 1-2.6 mmHg SBP reduction, adding a second agent from a different class provides a substantial additional 9 mmHg SBP and 5 mmHg DBP reduction (54) almost doubling the response of monotherapy. This approach also leverages different mechanisms of action, often leading to improved efficacy and a reduced incidence of dose- dependent side effects, as highlighted by trials like ACCOMPLISH (55) and meta-analyses (54,56).

Abbreviations: ACEI – angiotensin-converting enzyme inhibitor; ARB – angiotensin II receptor blocker; BMI – body mass index; CCB – calcium channel blocker; DASH – Dietary Approaches to Stop Hypertension; DBP – diastolic blood pressure; kg/m² – kilograms per meters squared; mg – milligrams; mmHg – millimeters of mercury; SBP – systolic blood pressure

IX. Recommendations

The evidence-based clinical practice recommendations listed in the table below were developed using a systematic approach considering four domains as per the GRADE approach (see Summary of Guideline Development Methodology). These domains include confidence in the quality of the evidence, balance of desirable and undesirable outcomes (i.e., benefits and harms), patient values and preferences, and other implications (e.g., resource use, equity, acceptability).

Table 4. Evidence-Based Clinical Practice Recommendations with Strength and Categorya,b

a For additional information, please refer to Determining Recommendation Strength and Direction b For additional information, please refer to Recommendation Categorization

A. Diagnosis and Monitoring

Recommendations

a. Measurement Technique

1. We suggest using attended or unattended, fully automated office blood pressure (AOBP)

measurement (programmed to wait five minutes and record the average of three measurements separated by at least 30 seconds). (Weak for | Reviewed, Not changed)

b. Monitoring

2. We suggest using home blood pressure monitoring (HBPM), ambulatory blood pressure monitoring (ABPM), or office blood pressure monitoring (OBPM) when necessary to further inform the diagnosis and/or management of hypertension. (Weak for | Reviewed, Amended)

Discussion

The diagnosis and management of HTN has been based primarily on measurement of blood pressure in the primary care office setting. Office measurements were used by most observational studies and all randomized controlled trials (RCTs) to define both the risk of various blood pressure levels and the goal blood pressures that lead to reduction in adverse cardiovascular outcomes or mortality. Historically, office blood pressure was measured manually using a mercury sphygmomanometer. However, manual office blood pressure (MOBP) measurements are no longer recommended due to human observer bias, calibration issues, and falsely elevated 'white coat' readings. Instead, recent studies have used fully automated oscillometric sphygmomanometers (automatic office blood pressure [AOBP]), programmed to have a five- minute wait time followed by two to three BP measurements separated by 30-60 seconds and report averaged results. During the 2020 CPG recommendation development, two SRs by Pappaccogli et al. (2019)(57) and Roerecke et al. (2019)(58) indicated that in-office blood pressure readings mimicking the technique used in the clinical studies were very similar to daytime average ambulatory blood pressure monitors (ABPM). Routine office readings, commonly performed as a single attended measurement (OBPM), were significantly higher than measurements from fully automated and averaged readings. A study by Bacaicoa et al. (2025)(59) again confirmed AOBP (waiting room or clinic room) had better diagnostic accuracy than office blood pressure measurement (OBPM). Other commonly performed methods of BP measurement include home blood pressure measurement (HBPM), kiosk blood pressure measurement, and ABPM to include 12-hour and 24-hour monitors.

The 2025 evidence review assessed the most accurate method for measuring blood pressure, resulting in the inclusion of four SRs and 17 individual studies. Apart from two studies, all compared a measurement method (HBPM, AOBP, MOBP, attended or unattended OBPM, waiting room blood pressure, kiosk blood pressure, and one-hour clinic AOBP) against ABPM as the reference standard. The reference standard in each study varied, with different thresholds for the diagnosis of HTN and different methods and duration for obtaining ABPM. In addition, some studies evaluated methods to establish the diagnosis of HTN, while other studies evaluated methods for monitoring therapy. An SR/meta-analysis (MA) by Karnjanapiboonwong et al.

(2020)(60) found that both AOBP and HBPM demonstrated acceptable diagnostic performance compared to ABPM, with only marginally better diagnostic accuracy than OBPM. Multiple individual studies compared OBPM or HBPM with ABPM and suggested these methods can help confirm HTN and guide treatment decisions.(61-64) Mizuno et al. (2023)(61) specifically found similar diagnostic accuracy for OBPM and HBPM, although both methods had limited ability to identify all individuals with high BP using ABPM. Due to the wide variety of methods utilized, variation in thresholds and the reference standard, as well as different indications for performing the measurement, no single method for measurement was found to be optimal. We suggest using any of the methods reviewed based on patient preference and availability of devices, as well as clinician concern for potential white coat HTN effect or masked HTN. Efforts should be made at the system level to ensure access to AOBP across primary care clinical settings in the VA and DOD.

The benefits of using HBPM, AOBP, and/or ABPM slightly outweigh the risks of these methods. Incorporating HBPM, ABPM, and AOBP can improve the diagnostic accuracy for hypertension and more accurately monitor treatment response compared to single office measurement. Although the risk to patients from blood pressure monitoring devices is very low, some discomfort may occur, particularly with 24-hour ABPM. However, these minor discomforts are justified by the clinical advantages of an accurate diagnosis and treatment.

There is large variability in the availability of blood pressure measurement methods. While most primary care clinics in the VA and DOD utilize oscillometric sphygmomanometers for measurement of office blood pressure, not all these devices have the hardware or software available to perform AOBP. The additional time required for AOBP compared to standard office measurement is another barrier to proper technique in office. Unlike patients in the DOD, patients in the VA have access to HBPM devices provided by the VA. ABPM availability varies across VA and DOD facilities and is currently insufficient to support routine use for the diagnosis and management of HTN for all patients. From the patient’s perspective, all available methods are generally acceptable although there may be individual preferences, with patients preferring the most accurate measurement.

The Work Group systematically reviewed evidence related to Recommendation 1.(57-59) Therefore, it is categorized as Reviewed, Not changed. The Work Group’s confidence in the quality of the evidence was very low. The body of evidence had limitations including that most studies compared a single measurement method to ABPM as a reference standard, leading to limited direct comparison between different measurement methods. The benefits of using AOBP include improved diagnostic accuracy to inform treatment decisions and alignment with the method used in the primary studies that demonstrate the benefits of treatment of hypertension. Although there is limited harm, such as patient discomfort, the benefits outweigh the negatives. Patient values and preferences vary; some patients prefer the convenience of HBPM, while others prefer in-clinic visits due to access to equipment. Thus, the Work Group decided upon a Weak for recommendation.

The Work Group systematically reviewed evidence related to Recommendation 2.(59-61,64-66) Therefore, it is categorized as Reviewed, Amended. The Work Group’s confidence in the quality of the evidence was very low. This body of evidence also had similar limitations, including that most studies compared a single measurement method to ABPM as a reference standard, leading to limited direct comparison between different measurement methods. There was no defined standard for the reference, and results were inconsistent across studies. The benefit of using a combination of HBPM, ABPM, and AOBP ensures an appropriate method is available to all patients, improves diagnostic accuracy by potentially detecting white coat and masked HTN, and helps inform treatment decisions. This is an update from the prior guideline which focused on out- of-office measurement methods. Similar to Recommendation 1, although there are some potential limited harms, such as patient discomfort, the benefits outweigh the potential burdens. Patient values and preferences vary; some patients prefer the convenience of HBPM, while others prefer in-clinic visits due to access to equipment. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation

3. We suggest offering home blood pressure self-monitoring with co-interventions (e.g., nurse or pharmacist-led educational interventions; or the use of various mobile apps) to improve adherence to therapy. (Weak for | Reviewed, Amended)

Discussion

Home blood pressure monitoring (HBPM) should utilize an automated blood-pressure cuff (either purchased by the patient or provided by the health-care system) to measure blood pressure at home so that trends of out-of-office blood pressure can be followed. Our evidence review included five SRs and 11 RCTs, which found greater adherence to therapy by patients who utilized HBPM both in isolation and in conjunction with a co-intervention. Co-interventions, such as nurse- or pharmacist-led education, or the use of various mobile apps, appear to more consistently improve adherence to therapy than HBPM alone. Both the 2014 and 2020 VA/DOD Hypertension CPGs recommend using HBPM for both diagnosis and treatment. Notably, Recommendation 5 within the 2020 update specifically notes that HBPM alone has a limited effect, but when paired with co-interventions, it significantly improves blood pressure control. The 2020 CPG also noted that HBPM, including tailored medication titration and education or lifestyle counseling, was associated with a lower blood pressure (MD [mean difference] in SBP - 6.1 mmHg). The current recommendation focuses only on the treatment of hypertension, specifically adherence to therapy, and achievement of blood pressure goals as the outcome.

The current recommendation is based on very low-quality evidence from an updated literature review.

Evidence for the use of HBPM without co-interventions was mixed. One RCT(67) demonstrated improved overall control of blood pressure in patients who were provided with a cuff to conduct four total BP measurements per week (82% vs. 54% achieving controlled hypertension), while another study demonstrated improved adherence to therapy (pill count) in patients with hypertension and diabetes when HBPM was paired with an education intervention.(68) Two other studies did not demonstrate significantly different adherence to therapy scores when patients were provided a home BP cuff with co-interventions.(69,70)

The impact was more notable when HBPM was paired with a co-intervention, such as nurse or pharmacist-led interventions or the use of HBPM with a mobile health app (mHealth). Medication adherence was measured using multiple objective methods across the studies, including pill counts, electronic medication monitoring, continuous multiple-interval gap metrics, prescription renewal ratio, and subjective questionnaire measurements.

Moderate-quality RCTs in the SR by Kim et al. (2023)(71) demonstrated that HBPM paired with nurse-led interventions produced a moderate impact on medication adherence and medication knowledge in patients with hypertension at risk for metabolic syndrome. Various types of interventions were utilized in these studies, but broadly they included provision of equipment/materials, education/discussion, and/or the use of a guideline/protocol/script, while patients met with providers individually or in group sessions. The interventions lasted a median of 12 weeks and most resulted in better adherence compared to usual care.

Similarly, moderate quality evidence from two RCTs demonstrated that HBPM paired with pharmacist-led face-to-face interventions resulted in better adherence to therapy than usual care, as measured by proportion of days covered or adherence to therapy questionnaires.(72,73) Both interventions utilized clinical pharmacists to educate patients, adjust medications, and encourage behavior changes, followed by frequent clinical evaluations. Conversely, pharmacy database reports given to providers (74) and enrollment of patients in therapeutic drug monitoring programs (75) did not produce greater adherence to therapy versus usual care.

The evidence for HBPM when paired with mHealth apps from two SRs is somewhat harder to assess, owing to significant heterogeneity in the type of applications utilized, as well as some inconsistent reporting of whether the applications required the input of HBPM results or if the applications were more focused on items such as medication reminders or behavior changes. The overall quality of evidence ranged from very low to moderate, and the results indicate the use of multiple kinds of mHealth apps improves adherence to anti-hypertensive therapy.(76,77) It was not possible to draw definite conclusions regarding the superiority of one type of application over another. App-based behavioral self-monitoring interventions had a small but significant effect in reducing SBP, on average, by 1.7 mmHg. A subgroup analysis revealed that behavioral self-monitoring interventions paired with tailored advice led to significantly greater improvements in both SBP and DBP than interventions lacking tailored advice. Additionally, there was evidence that an electronic reminder device alone did not lead to significant improvement in medication adherence to therapy, though this was a small study with few patients.(78)

The Work Group systematically reviewed evidence related to this recommendation.(71- 73,76,77) Therefore, it is categorized as Reviewed, Amended. The Work Group’s confidence in the quality of the evidence was very low. The body of evidence had some limitations including heterogeneity in interventions, possibly unrelated clinical outcomes (e.g., improved medication adherence by a clinical adherence scale rather than improved blood pressure control in some studies), and lack of discussion on the cost of certain interventions. Co-interventions provide personalized patient feedback with actionable items versus static data points from HBPM without co-interventions. Benefits demonstrated in the studies include improved adherence by

B. Treatment Goals and General Approaches to Hypertension Management

a. Blood Pressure Goals

Recommendation

4. For individuals with hypertension, we recommend treating to a target systolic blood pressure goal of <130 mmHg to reduce adverse cardiovascular outcomes, depending on patient characteristics and preferences. (Strong for | Reviewed, New-replaced)

Discussion

Pharmacological treatment of HTN has been shown to decrease the risk of adverse cardiovascular events, including in those with co-occurring diabetes, CKD and heart failure with preserved ejection fraction (HFpEF). Two SRs by Haze et al. (2025) and Rizwanullah et al. (2025) including 24 RCTs performed in a relatively broad population with HTN provided moderate strength of evidence that intensive blood pressure lowering to a SBP target of less than 130 mmHg, as compared to a higher target (SBP <140-150 mmHg), reduces composite cardiovascular outcome, which included stroke, non-fatal myocardial infarction and death from cardiovascular causes.(80,81) An additional SR by Matsumoto et al. (2025) found no significant difference in composite cardiovascular outcome in individuals with HFpEF; however, the effect size was virtually identical to the above SRs.(82) The evidence for intensive BP lowering in individuals with HTN and concurrent diabetes was not reviewed separately; nevertheless, individuals with diabetes were included in several RCTs that were analyzed in the SRs.(83-85) Dedicated SR (86) focusing on specific populations with CKD did not report composite cardiovascular outcomes, but patients with CKD were included in several RCTs generating the evidence for other SRs.(80-82) There was also a moderate strength of evidence that intensive treatment to a SBP goal of <130 mmHg, as compared to a higher target (SBP ≥130 mmHg), reduces the risk of two individual outcomes, such as stroke(81), based on one SR of 12 RCTs, and cardiovascular death, based on two SRs of 24 RCTs.(80,81) Despite the similar effect size and direction of evidence, cardiovascular death risk reduction did not reach statistical significance in subpopulations with CKD or HFpEF.(82,86) There was also moderate evidence from one SR including 12 RCTs that intensive systolic blood pressure control (SBP goal <130 mmHg) reduces risk of heart failure in the general population with HTN (81), and is also associated with a reduction in heart failure hospitalizations among individuals with HFpEF in another SR.(82) Other vital outcomes, such as all-cause mortality and coronary events, were not reduced with more intensive lowering of BP. There were no studies comparing even more intensive BP lowering to a SBP goal <120 mmHg with an SBP goal of <130 mmHg.

It is important to note that targeting HTN treatment to a SBP goal of <130 mmHg as compared with SBP <140 mmHg was associated with increased risks of hypotension, syncope and acute kidney injury, but not with increased risks of falls associated with injury or in progression of CKD, including in subpopulations with CKD.(80-82,86) Although not reviewed as separate evidence for this CPG, an increasing number of contemporary RCTs, including those in systematically reviewed SRs, utilized the automated office BP (observed or unobserved) using a programmable device that takes automated BP measurements after five minutes rest and averages several BP values.(80,81) The previous SR by Roerecke et al. (2019) demonstrated that BP values obtained with automated office BP (as suggested in Recommendation 1), are significantly lower (as much as a 14 mmHg difference) than BP values obtained with routine office BP measurement technique.(58) Additionally, clinical trials targeted average SBP values across multiple follow-up visits rather than BP values from a single visit.

Generally, persons with hypertension and frailty, cognitive impairment, concomitant orthostatic hypotension, and octogenarians/nonagenarians were excluded from clinical trials targeting intensive BP control.

The Work Group systematically reviewed evidence related to this recommendation. (80-82,86) Therefore, it is categorized as Reviewed, New-replaced. The Work Group’s confidence in the quality of the evidence was moderate. The benefits of targeting a SBP goal of <130 mmHg in the general population with HTN outweigh the potential harms, which include hypotension, syncope and acute kidney injury. Individual values and preferences vary somewhat; however, most agree that avoiding cardiovascular disease, especially stroke, is critical. Shared decision-making between providers and individuals with HTN, with considerations that strike a balance between risk and benefits of intensive BP lowering is important. Targeting a lower SBP goal usually requires a higher number of antihypertensive drugs, which some people would prefer to avoid, and some are unwilling to take. Additionally, some individuals may not achieve the desired SBP goals without experiencing adverse drug reactions. During the patient focus group, concerns about polypharmacy and potential side effects of more intensive BP lowering were confirmed; however, everyone agreed that avoidance of stroke and cardiovascular disease would shift the balance toward lower SBP goals. Other considerations when treating to a lower SBP goal are the need for more frequent visits for titration and monitoring of side effects of antihypertensive drugs, which may increase resource utilization and contribute to the treatment burden of the individual. Thus, the Work Group decided upon a Strong for recommendation.

Recommendation

5. For individuals ≥30 years old with hypertension, we suggest treating to a target diastolic blood pressure goal of <90mmHg to reduce adverse cardiovascular outcomes, depending on patient characteristics and preferences. (See Recommendation 6) (Weak for | Reviewed, Amended)

Discussion

No new studies have addressed the benefits of lowering DBP to a goal of <90 mmHg to compare with higher targets since the publication of the 2020 VA/DOD HTN CPG. It is unlikely that such studies will be performed in the future because lowering SBP to a target of <130 mmHg was generally accompanied by a reduction in DBP to <90 mmHg. Therefore, the Work Group reviewed the evidence from the 2020 VA/DOD HTN CPG, which included 17 publications from 11 RCTs consisting of 59,304 participants.(87) Seven publications compared two different DBP targets, thus providing direct evidence for benefit or harm of different goals, while five publications compared treatment to a DBP target with an active drug compared to a placebo, and another five additional articles compared a DBP target to the usual care, thus providing indirect evidence for the question of treatment goals. Landmark studies, such as the Veterans Administration Cooperative Study Group on Antihypertensive Agents, the Hypertension Detection and Follow-up Program (HDFP), and the Medical Research Council (MRC) trial of treatment of mild HTN, as well as SR and meta-analysis by Saiz et al. (2018), all demonstrated substantial cardiovascular benefits by treating to a target DBP of <90 mmHg.(85,88-92) Eligibility for these studies differed somewhat, but all included patients 30 years of age or older. This recommendation may or may not apply to individuals aged 18 to 29, as clinical trials did not include patients younger than 30. However, it is unlikely that clinical trials will address HTN treatment and optimal DBP targets in younger adults, given the low prevalence of primary HTN in this group. The Work Group believes that younger adults with elevated DBP may also benefit from treatment.

The Work Group systematically reviewed evidence related to this recommendation in the evidence review from the 2020 VA/DOD HTN CPG.(88) Therefore, it is categorized as Reviewed, Amended. The Work Group’s confidence in the quality of the evidence was low due to serious study limitations, indirect comparisons and imprecision. The benefits of targeting a DBP goal of <90 mmHg in the general population aged 30 and older with HTN outweigh the potential harms. Other considerations regarding this recommendation included the lack of data from patients under 30 years, thus the specified age range. Therefore, the Work Group decided upon a Weak for recommendation.

Recommendation

6. For individuals with hypertension, there is insufficient evidence to recommend for or against treating to a target diastolic blood pressure goal of <80 mmHg, versus a target of <90 mmHg. (Neither for nor against | Reviewed, New-added)

Discussion

Several recent guidelines on HTN, including the American College of Cardiology/American Heart Association 2025 CPG (11), recommend treating to a target of DBP <80 mmHg. The current CPG reviewed evidence from three SRs that compared DBP targets; two SRs (93,94) focused on general population with HTN and one SR (95) focused on older adults. Evidence from three RCTs in a 2020 SR by Baffour-Awuah et al. (2020) found no difference between groups with DBP <80 mmHg vs. higher targets (<85 or <90 mmHg) for major cardiovascular events during 3.8 to 4.9 years of follow-up. Three individual RCTs from a 2022 SR by Reboldi et al. (2022) demonstrated a 19-26% risk reduction of myocardial infarction (MI) with DBP <80 mmHg, as compared with DBP 80-89 mmHg. However, SRs by Arguedas et al. (2020) and Baffour-Awuah et al. (2020) analyze an overlapping (but not identical) set of RCTs and found no significant between-group difference in risk of MI, although effect sizes were similar in all three SRs.(93-95) Evidence from five RCTs in three SRs (93-95) found no difference in the risk of stroke between groups with DBP <80 mmHg as compared with DBP 80-89 mmHg during 3.8 to 5.3 years of follow-up. The total adverse events were only reported from one RCT in one SR and the risk was not increased; however, that study included a limited number of participants (N=338) and had a relatively short follow-up period (19 months).(75)

Sub-analysis of systolic versus diastolic BP treatment targets in Baffour-Awuah et al. (2020) showed that achieving lower SBP was significantly more effective in reducing the relative risk of cardiovascular events as compared with DBP. Although not reviewed as separate evidence, the mean achieved DBP in RCTs evaluating SBP goals <120 vs. <140 mmHg was below 80 mmHg in all treatment groups, suggesting that lower DBP is achievable in most individuals treated to a target SBP <130 mmHg and it is tolerated without increased untoward effects.(84,96,97)

The Work Group systematically reviewed evidence related to this recommendation.(93-95) Therefore, it is categorized as Reviewed, New-added. The Work Group’s confidence in the quality of the evidence was low due to concerns with methodological quality of the included RCTs and wide confidence intervals (CIs) in the reported outcomes. There is inconsistent benefit of lowering DBP <80 mmHg as compared with higher targets, but also no apparent increase in adverse events. Most individuals in whom SBP is targeted to <130 mmHg will also achieve DBP targets of <80 mmHg. Thus, the Work Group decided upon a Neither for nor against recommendation.

b. General Approaches to Hypertension Management

Recommendation

7. We suggest offering pharmacist-led medication management to achieve blood pressure goals. (Weak for | Reviewed, New-replaced)

Discussion

This recommendation is intended for pharmacists in the clinic setting in both the VA and DOD, and not dispensing pharmacists. Pharmacist-led interventions have been effective in improving critical outcomes in hypertensive patients. Interventions evaluated during this evidence review include medication-focused interventions (medication initiation, adjustment, and recommendations to physicians) as well as sessions on adherence, lifestyle modification, blood pressure measurement, support for home blood pressure monitoring, and patient education. One SR by Mills et al. (2024) was identified for review in this CPG update.(51) Pharmacist-led interventions from 29 RCTs including 7,476 patients with hypertension demonstrated net changes in both SBP (-7.3 [95% CI, -9.1 to -5.6] mmHg) and DBP (-3.9 [95% CI, -5.2 to -2.5] mmHg) compared to usual care or minimal education.(51) Pairwise comparisons showed statistically greater reductions in BP with pharmacist-led interventions than with nurse-, physician-, or multiple-leader-led interventions.(51) Pharmacists' ability to titrate medications may partially explain the large net BP reduction observed in the reviewed trials. A smaller but still significant reduction in BP was seen after adjustment for implementation strategy (-6.4 [95% CI, -9.0 to -3.8] mmHg for SBP and -3.8 [95% CI, -6.2 to -1.4] mmHg for DBP), however, suggesting that BP lowering was not solely due to medication management.(51) Pharmacists’ expertise uniquely positions them to provide medication titration as well as effective counseling on other aspects of medication support, such as adherence and side effects, which are often barriers for patients.

Structure, staffing, and resources vary between the Medical Home Model (DOD) and Patient Aligned Care Team Model (VA), as well as by treatment environment. Dedicated pharmacy staff for the interventions reviewed may be limited or unavailable in some facilities or locations, such as deployment settings. Focus group data indicated that patients highly value personalized treatment plans and finding medication(s) that are effective and minimize side effects. Access to a pharmacist at VA and DOD medical facilities for discussion of pharmacotherapy options and/or medication management was uncommon but desired by participants.

The Work Group systematically reviewed evidence related to this recommendation.(51) Therefore, it is categorized as Reviewed, New-Replaced. The Work Group’s confidence in the quality of the evidence was low. The body of evidence had some limitations, such as difficulty masking those delivering the intervention or study participants. Some cluster trials did not enroll all study participants before randomization, and many older trials lacked prespecified statistical analysis plans. Additionally, the SR studies had modest sample sizes in some intervention- delivery categories. Significant heterogeneity was observed across all comparisons. The benefits of improved SBP and DBP outweigh the potential harm; it should be noted that Mills et al. (2024) did not report adverse events.(51) Patient values and preferences vary somewhat. Some may prefer interventions less focused on medications, whereas others highly value pharmacists’ expertise in individualizing medication regimens to maximize effectiveness and minimize side effects. Thus, the Work Group decided upon a Weak For recommendation. The change from a Strong for in 2020 to a Weak for recommendation does not reflect evidence showing a smaller effect size, rather a stricter application of the GRADE methodology.

Recommendation

8. We suggest offering nurse-led interventions as an option for blood pressure management.

(Weak for | Reviewed, Not changed)

Discussion

Nurse-led interventions for the management of HTN encompass a wide variety of treatment approaches, including sessions for medication adherence, lifestyle modification, BP measurement, protocol-based medication adjustment, support for HBPM, education materials, personalized therapeutic plans, and goal setting. Mills et al. (2024) included 19 studies (n=9,453) which evaluated nurse-led interventions against usual care or minimal education and found reductions in SBP (-3.0 [95% CI, -4.2 to -1.9] mmHg) and DBP (-1.8 [95% CI, -2.6 to -1.0] mmHg).(51) In general, nurse-led interventions are well received by patients and most providers. Patients often appreciate nurse-led interventions for increased or more timely access to care and shorter wait times related to seeing a primary care provider.

The Work Group systematically reviewed evidence related to this recommendation.(51) Therefore, it is categorized as Reviewed, Not changed. The Work Group’s confidence in the quality of the evidence was low. The body of evidence had some limitations, including difficulty masking those delivering the intervention or study participants; some cluster trials did not enroll all study participants before randomization, and many older trials lacked prespecified statistical analysis plans. Additionally, the SRs had modest sample sizes in some intervention-delivery categories. Significant heterogeneity was observed across all comparisons. The benefits of improved blood pressure outweigh the potential harms (none identified). Patient values and preferences vary somewhat. Interest and ability to modify lifestyle varies, as does receptiveness to medications; the nurse-led interventions reviewed for this update included components of both lifestyle and medication management. Additionally, some patients may prefer not to have additional healthcare appointments. The patient focus group did not explicitly discuss nurse-led interventions, but participants were enthusiastic about support options for lifestyle changes to improve blood pressure. The feasibility of implementing nurse-led interventions may vary based on local staffing resources. Other potential barriers include challenges with workload reimbursement and time limitations in clinic visits to provide health-coaching. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation

9. We suggest offering registered dietitian-led nutrition interventions as an option for blood pressure management. (Weak for | Not reviewed, Not changed)

Discussion

New evidence for dietitian-led interventions was not reviewed as part of this CPG update. Evidence from the 2020 VA/DOD HTN CPG update found that registered dietitian-led nutrition interventions, such as counseling on sodium restriction, weight loss, and increasing consumption of fruits and vegetables, resulted in modest but statistically significant lowering of SBP and DBP in treated and untreated hypertensive individuals when compared to usual care.(50) A systematic review by Reigel et al. (2018), which included 2,050 patients across 13 RCTs, demonstrated that nutrition-based interventions resulted in lower SBP (MD -2.9 [95% CI, -4.0 to -1.7] mmHg) and lower DBP (-1.4 [95% CI, -2.1 to -0.6] mmHg) compared to usual care.(50) However, when studies were grouped based on whether the nutrition intervention was delivered by a registered dietitian versus other practitioners, the reduction in SBP was only significant for nutrition interventions with a registered dietitian and the effect size was larger (- 3.2 [95% CI, -4.1 to -2.3] mmHg). The greatest reductions in SBP were seen for dietitian-led nutrition interventions which included sodium restriction as one of the recommendations (-3.5 [95% CI, -4.5 to -2.5] mmHg). Significant lowering of DBP (-1.4 [95% CI, -2.1 to -0.6] mmHg) was seen for nutrition interventions compared to usual care, with a larger reduction (-1.7 [95% CI, -2.4 to -1.0] mmHg) when the intervention included both a registered dietitian and sodium restriction. The Work Group did not systematically review new evidence related to this recommendation. Therefore, it is categorized as Not Reviewed, Not Changed. The Work Group’s confidence in the quality of the evidence was low. The body of evidence had some limitations including a lack of uniformity across trials (i.e., nature and duration of interventions and assessment of outcomes); however, 13 out of 15 studies showed moderate heterogeneity.(50) Riegel et al. (2018) also noted a lack of blinding of investigators, a lack of allocation concealment, and concerns about subgroup analysis due to the small number of studies without a registered dietitian. The benefits of modest improvement in SBP and DBP outweighed the potential harm of additional clinical appointments, which may be perceived as burdensome, but no harms were reported from nutritional interventions. The Work Group expects there is variation in both interest and ability to modify diet. Patient preferences vary somewhat, as some patients may be resistant to changing eating patterns or face geographical barriers, such as in food deserts or deployment settings, as well as financial barriers to accessing certain types of healthy foods. Others may have high levels of motivation to improve diet quality to reduce pill burden. Focus group participants expressed a strong desire for individualized care, with many preferring treatment plans that include education on dietary modification and other lifestyle changes, rather than relying solely on medications. Access to a registered dietitian and wait times may also vary at different facilities based on staffing and appointment availability. Working with a registered dietitian can provide individualized guidance on improving nutrition within these constraints, as well as factoring in personal and cultural food preferences. There is also the potential to improve other comorbidities with dietary modification. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation

10. We suggest offering one or more of the following digital health technologies, as an adjunct to usual care to improve blood pressure control: • App or text-supported remote home blood pressure monitoring system, • Patient messaging, • Smartphone applications, • Web-based platforms for management. (Weak for | Reviewed, New-replaced)

Discussion

Evidence reviewed during this CPG update showed that digital telehealth interventions added to usual care protocols resulted in reductions of SBP variability. The strength of the evidence was low in favor of the additional digital health interventions as adjunct to usual care and aiding in the reduction of SBP. Digital health interventions, when integrated with standard care protocols, improved accessibility, engagement, and adherence. Continued monitoring, real-time feedback, and access to educational resources supported a more personalized care experience. Patients and healthcare providers may communicate through individual or group messaging and virtual audio-video platforms. Push notifications are also commonly used for reminders, including appointments and metric updates.

Siopis et al. (2023)(98) conducted an SR and meta-analysis that synthesized data from 29 RCTs consisting of 7,592 participants across 13 regions. The analysis evaluated effectiveness, reach, uptake, and feasibility of digital health interventions in adults with hypertension. Average reductions of -3.6 mmHg (SBP) and -2.5 mmHg (DBP) were observed. Individuals with chronic or complex hypertension saw larger reductions. Smartphone interventions showed the most statistically significant results, whereas short message service (SMS) and websites reached a larger audience and were more accessible.

Kelly et al. (2025)(99) conducted a meta-analysis that synthesized data from 75 RCTs consisting of 106,261 participants. The analysis evaluated effectiveness of digital health interventions in adults with hypertension (n=79,035) and Type 2 diabetes mellitus (n=27,226). Reductions in SBP (average -4.9 mmHg) and DBP (average -2.0 mmHg) were observed along with modest secondary benefits related to Hemoglobin A1c (HbA1C) reduction (average - 0.42%) in pre-diabetic/diabetic individuals.(98,99) Interventions assessed included virtual clinics/consultations, online platforms, telephone applications, and telephone text messages.

Kaihara et al. (2022)(52) conducted a systematic review and meta-analysis that synthesized data from 23 RCTs consisting of 5,743 participants across multiple regions related to home blood pressure telemonitoring (HBPT) systems with automatic data transmission. Average reductions of 6.0 mmHg for SBP and 2.4 mmHg for DBP were observed. Data transmission was achieved via BP data feedback programs, phone lines, Bluetooth, and smartphone applications. Some smartphone applications deployed a multi-disciplinary care model to include access to virtual nurses and pharmacists. Study duration ranged from 4 to 72 weeks, with an average duration of 27 weeks. The average completion rate for the included studies was 89.5%.(52)

Motta-Yanac et al. (2025)(53) conducted an SR and meta-analysis that synthesized data from 36 studies which included 26 RCTs consisting of 33,826 participants. The analysis evaluated effectiveness of digital health interventions (smartphone applications) in adults with hypertension. Average reductions of 1.6 mmHg in SBP and 0.6 mmHg in diastolic blood pressure were observed. Smartphone application interventions showed reductions in SBP (-1.9 [-3.4 to -0.6] mmHg) and were a more effective delivery method than SMS and phones calls, which showed no impact.(53,98)

The Work Group systematically reviewed evidence related to this recommendation.(52,53,98,99) Therefore, it is categorized as Reviewed, New-replaced. The

Work Group’s confidence in the quality of the evidence was low with the suggestion of modest overall benefit for SBP reduction when digital interventions are used adjunct to usual care. The body of evidence had some limitations, including lack of evaluation standardization, reporting, and masking bias. Some of the studies included in the SR demonstrated reductions in SBP when digital health interventions were added as adjunct to usual care. Statistical impact varied largely due to the variety of digital health interventions evaluated. The benefits of digital health technologies for hypertensive patients outweighed the potential harms, such as device/technology dependency and data inaccuracy due to calibration/user error. Patient values and preferences vary largely due to willingness to learn new technologies and some patients may desire not to use technology. Additional factors supporting a Weak for recommendation include acceptability, feasibility, equity, and subgroup considerations such as marketplace availability and end-user uptake. Availability of digital health interventions depends on what is offered by the treatment facility or nearby civilian institutions. The willingness of patients and providers to use digital health interventions and device-enabled features should be carefully assessed. Asynchronous and synchronous data collection, as well as device validation, should also be considered. Thus, the Work Group decided upon a Weak for recommendation.

C. Pharmacological Interventions

Recommendation

11. For individuals with hypertension, we recommend a thiazide-type diuretic, dihydropyridine calcium channel blocker, or either an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker, as primary pharmacologic therapy to reduce adverse cardiovascular outcomes. (Strong for | Reviewed, Amended)

Discussion

The effects of the various antihypertensive drug classes on reducing adverse cardiovascular outcomes, and not just differences in blood pressure lowering effect, were the focus for the recommendation in 2020 and reaffirmed for the 2026 update. The SR and meta-analysis of 50 RCTs by Thomopoulos et al. (2015) was the key body of evidence reviewed in 2020 to recommend these four main drug classes as initial therapy for HTN.(100) Head-to-head comparisons of different antihypertensive drug classes were made for the critical and important outcomes. The components of the critical outcome from the SR included the composite of fatal or nonfatal stroke and coronary heart disease (CHD) events (coronary death and nonfatal MI), both with and without hospitalizations for heart failure. In patients with HTN, the SR found that angiotensin-converting enzyme inhibitors (ACEIs) were equivalent to angiotensin II receptor blockers (ARBs); ACEIs were equivalent to thiazide-type diuretics; and calcium channel blockers (CCBs) were equivalent to thiazide-type diuretics for composite cardiovascular outcomes. No significant differences in the critical outcome were found for the comparisons of ACEIs and CCBs or ARBs and CCBs; however, the conclusion about their equivalency could not be determined.(100) The evidence base for CCBs included several types of research: a mix of all CCBs; subclasses of CCBs (e.g., dihydropyridine [DHP] CCBs and non-dihydropyridine [non-DHP]); and long-acting formulations. Without literature reporting a head-to-head comparison, we did not have evidence for a recommendation specific to any particular sub-class of CCB.

Various formulations of CCBs, including long-acting CCBs (LA-CCBS), may have different effectiveness and safety profiles that prescribers should consider.

Updated evidence identified during this review was restricted to comparative effectiveness studies and included two network meta-analyses (NMA), three SRs, and three RCTs. The comparisons varied in classes of drugs vs. individual drugs and the outcomes evaluated. In total, there is insufficient data to inform on a preference of one class of agents vs. another for primary pharmacologic therapy (e.g., ACEIs, ARBs, CCBs, or thiazide-type diuretic).There were an extensive number of comparisons that addressed various cardiovascular outcomes with some mixed results. Several comparisons found no differences in cardiovascular outcomes. Notable findings where differences were observed included that ACEIs, ARBs, and diuretics were superior to CCBs for heart failure (low quality evidence from two SRs)(101,102) and CCBs and diuretics were superior to ACEIs for stroke reduction (moderate quality evidence from two SRs and one NMA).(101-103)

ACEIs and ARBs are not used concomitantly, due to well-recognized safety risks.

Although the evidence did not support a recommendation, providers can consider beta blockers as an alternative to the four main antihypertensive classes for patients with compelling indications, including those with underlying CAD, following MI, and in heart failure with reduced ejection fraction. Patients who are intolerant to the four main antihypertensive drug classes may also consider a beta blocker. The Thomopoulos et al. (2015) SR found beta blockers were equivalent to ARBs for the composite cardiovascular outcomes and reported no significant difference between beta blockers and CCBs or thiazide-type diuretics.(100) There were no critical outcomes reported for beta blockers compared to ACEIs. Some important outcomes showed beta blockers were inferior to the other drug classes, particularly for stroke reduction.(100) The 2026 updated evidence review supports beta-blockers as an alternative agent rather than primary therapy. One SR by Zhu et al. (2021) found that CCBs were superior to beta-blockers for major adverse cardiovascular events (MACE), and stroke (both moderate quality evidence), as well as cardiovascular death (low quality evidence).(102) Two SRs (101,102) found that thiazides were superior to beta-blockers for cardiovascular events (moderate quality of evidence), and one NMA (55 RCTs)(103) showed that ACEIs were superior to beta-blockers for CV and all-cause mortality (low quality evidence). Beta blockers are not recommended as initial antihypertensive therapy, as the evidence is mixed as to whether there is a clear benefit in reducing cardiovascular events.

The Work Group agreed on a Strong for recommendation due to the robust and extensive body of evidence from RCTs, meta-analyses, and SRs supporting use of four drug classes (e.g., thiazide-type diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers).(100-103) Therefore, it is considered a Reviewed, Amended recommendation, to clarify that the evidence base evaluated individual adverse cardiovascular outcomes as well as composite cardiovascular outcomes. The confidence in the quality of evidence was moderate, as the authors of the SR adjusted outcomes so that the blood pressure reductions in each drug class were similar.(100) This led to the conclusion that antihypertensive drugs from the same classes have the same blood pressure lowering effect, which may or may not be true. However, overall, the consensus of the Work Group was that the critical and important outcome results supported that the four antihypertensive drug classes produced similar effects on reducing adverse cardiovascular events. Thomopoulos et al. (2015)(100) did not evaluate differences in adverse events, and the 2026 evidence review did not identify any relevant differences in adverse events. The Work Group concluded that the benefits of the reduction in adverse cardiovascular outcomes outweighed the harms, including the AEs associated with pharmacologic therapy (e.g., orthostatic hypotension, increases in serum creatinine, hyperkalemia, other metabolic concerns) along with other often-manageable side effects, and the risks associated with foregoing drug treatment. Although the four main drug classes for initial therapy were supported by the evidence, there is still some variation, as individual patients may show differences in personal choices, including tablet burden and frequency of medication administration. Additionally, patient-to-patient variation in tolerability of AEs can be a factor when choosing a particular antihypertensive drug class. This variability was also supported by the patient focus group, during which some of the patients indicated that providers focused on pharmacological therapies, rather than providing information and education on non-pharmacologic treatments. An important implication in terms of resource use is cost. Drug copayments for VA and TRICARE beneficiaries vary depending on factors such as dispensing venue (e.g., military treatment facilities versus mail order) and whether a generic versus branded formulation is dispensed. Cost may be less of an issue for active-duty personnel, who receive their medications at no cost. Thus, the Work Group decided upon a Strong for recommendation.

Recommendation

12. For individuals with hypertension 65 years and older, we suggest a thiazide-type diuretic to reduce adverse cardiovascular outcomes. (Weak for | Not reviewed, Amended)

Discussion

In hypertensive patients over the age of 65, treatment with a thiazide-type diuretic compared to other treatment options has been shown to reduce composite cardiovascular outcomes which included heart failure and stroke.(104) In this same meta-analysis (Thomopoulos et al. [2018]), beta-blockers were less effective than all other therapies. For patients over 65, there were no significant differences in composite outcomes between CCBs, ACEIs, and ARBs. It is important to note that the age of 65 is an arbitrary cut-off that was used in this single meta-analysis, thus resulting in a Weak for recommendation. Individual trials have used various age cut-offs for enrollment. Furthermore, this meta-analysis reported similar outcomes with an age cut-off of 60, compared to 65. Large RCTs are consistent with this recommendation, specifically ALLHAT, which is especially pertinent to VA/DOD providers due to the more than 7,000 Veterans included in the study.(105) Of note, ALLHAT enrolled patients age 55 and over and demonstrated improved CVD outcomes with chlorthalidone compared to amlodipine or lisinopril. Harms of thiazide-type diuretics versus other therapies were considered, but a meta-analysis of adverse events did not demonstrate any significant difference between thiazide-type diuretics and other therapies.(104) In general, the evidence supports the use of thiazide-type diuretics in older patients with HTN over other classes of medication.

While there is strong evidence that thiazide-type diuretics in general reduce composite cardiovascular outcomes, there is significant variability between agents in the thiazide-type diuretic class. The strongest trial evidence for improved CVD outcomes with thiazide-type diuretics involves chlorthalidone and indapamide, from ALLHAT(105) and the Hypertension in the Very Elderly Trial (HYVET)(106), respectively. In Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH), the ACEI/CCB combination was favored over an ACEI/thiazide-type diuretic combination.(55) The dose and type of the thiazide-type diuretic in ACCOMPLISH (hydrochlorothiazide [HCTZ] 12.5- 25 mg/day) was lower than equipotent doses of chlorthalidone or indapamide. For initial or add- on treatment of HTN, chlorthalidone and indapamide result in more substantial decreases in blood pressure compared to low doses of HCTZ (12.5-25 mg/day). However, when chlorthalidone and HCTZ are used in equipotent doses (12.5-25 mg of chlorthalidone compared to 25-50mg of HCTZ), there were no differences in blood pressure control and cardiovascular outcomes.(107) Patient preferences may vary based on the requirement for laboratory monitoring with thiazide-type medications.

Although not included in the evidence review, the authors of a recent (Musini et al. [2025]) systematic review of composite cardiovascular outcomes in over 29,000 hypertensive individuals 60 years and older found that there was no new evidence since their previous review in 2019. composite cardiovascular outcomes more than other classes of antihypertensive agents.(108) An additional pragmatic clinical trial published in 2022 found no differences in cardiovascular outcomes among over 13,500 VA participants who were 65 years or older taking hydrochlorothiazide in a dose of at least 25 mg. They were then randomized to continue hydrochlorothiazide vs. a comparable number of participants were randomized to a pharmacologically equivalent dose (12.5 or 25 mg daily) of chlorthalidone.(107) 95% were on the lower doses of HCTZ (25 mg daily) or chlorthalidone (12.5 mg daily).

The Work Group systematically reviewed evidence related to this recommendation from the 2014 VA/DOD Hypertension CPG.(104,105) Therefore, it is categorized as Not reviewed, Amended. The Work Group’s confidence in the quality of the evidence was moderate. The benefits outweigh the potential harm due to cardiovascular risk and blood pressure reduction, although there could be side effects from the medications. Patient values and preferences vary somewhat, because some patients may find the potential side effects to be intolerable, such as edema. Other implications include feasibility, acceptability, and subgroup considerations due to VA/DOD formulary considerations. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation

13. For individuals on maximally tolerated triple therapy (i.e., a thiazide-type diuretic; calcium channel blockers; and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker), who have not achieved blood pressure control, we suggest adding spironolactone or amiloride. (Weak for | Reviewed, Amended)

Discussion

The mineralocorticoid receptor antagonist (MRA) spironolactone more effectively reduces SBP and DBP compared to placebo and alternative antihypertensive agents (see below) when added as the fourth agent to the treatment regimen of patients with resistant HTN (RHTN). More specifically, in the PATHWAY 2 randomized controlled trial (n=335), spironolactone was significantly more effective than bisoprolol, doxazosin, and placebo in RHTN patients, reducing home SBP by 8.8 mmHg more than placebo, and 4.3 mmHg more than the other two active drugs. Nearly 60% in the spironolactone arm achieved their target BP compared to 40% in the other two active agent arms.(109) These findings are supported by a meta-analysis that included 24 RCTs consisting of 3,458 patients with RHTN, which compared 12 active pharmacologic or interventional treatments for RHTN to one another or placebo/sham.(110) Fourteen of the RCTs reported on pharmacologic interventions. In all pharmacologic comparisons, spironolactone was the only agent that showed a statistically significant reduction in blood pressure over other agents (e.g., guanfacine).

In the recent SPARE randomized controlled trial from Korea (n=118), amiloride (an epithelial sodium channel blocker) was noninferior to spironolactone for lowering both SBP and DBP.(109,111) As such, amiloride may be considered as an effective alternative to spironolactone with the benefit of avoiding adverse effects of gynecomastia and mastodynia. Eplerenone (a more selective MRA) is another alternative with lower risk of side effects, although this was not part of our evidence review since there are no randomized trials in patients with RHTN comparing eplerenone to spironolactone. From a safety perspective, spironolactone, eplerenone, and amiloride all consistently resulted in a modest increase in serum potassium, which requires monitoring, particularly at the start of therapy or after dose titration.

Compared with spironolactone, the addition of other antihypertensive drugs to the three-drug regimen of patients with RHTN were less effective in reducing blood pressure (e.g., beta- blockers and alpha blockers).(109) There is very limited, older data supporting the use of central sympatholytic drugs (clonidine, guanfacine) and vasodilators (hydralazine, minoxidil); therefore, these should only be used if all prior medication classes cannot be used or tolerated, or provide an inadequate blood pressure response.(112)

In patients with a history of hyperkalemia and diminished renal function, spironolactone, amiloride, and eplerenone should be used cautiously and with frequent monitoring of potassium and renal function (within one week of initiation). It should be used with extreme caution in patients with an estimated glomerular filtration rate (eGFR) less than 45 ml/min/1.73m² or a serum potassium of 5 millimole (mmol)/liter or greater. Since spironolactone has both antiandrogenic and endocrine effects, it should also be used cautiously in patients with menstrual irregularities, mastodynia, gynecomastia, or sexual dysfunction. Regardless of baseline risk, patients should be informed of and monitored for potential anti-androgenic side effects (e.g., gynecomastia in 5-10% of cases). Should intolerable side effects arise, alternative non-inferior agents should be offered with lower risks of gynecomastia or sexual dysfunction.

Before adding a fourth drug to the treatment regimen, medication adherence and the feasibility of required laboratory monitoring should be assessed. Single-pill combination medication (SPCM) may improve adherence. Cost and access concerns should also be considered when prescribing new agents versus generic options. Particularly if medication adherence is a concern, the risks/benefits of non-pharmacologic therapies (e.g., low sodium, diet, exercise, renal denervation) should be discussed with each patient through a shared decision-making process. Spironolactone interferes with tests that assess for hyperaldosteronism, a secondary form of HTN, so initiation should be postponed at least four weeks if such tests are anticipated but not yet completed.

If spironolactone or amiloride or other alternatives are not tolerated or cannot provide an adequate response in blood pressure, there are recent randomized trials supporting the use of newer agents for RHTN. Aprocitentan, an endothelin receptor antagonist, was evaluated in the PRECISION trial (n=730), which demonstrated modest efficacy compared to placebo (placebo- adjusted drop [25 mg dose] of 3.7 mmHg office SBP and 5.9 mmHg 24h ABPM at four weeks, with sustained effect at 48 weeks); it has not yet been compared in head-to-head trials with other alternative agents, and hence its overall place in therapy is unclear.(113) Novel aldosterone synthase inhibitors (ASI) have also demonstrated efficacy compared to placebo and may offer an alternative to other fourth-line agents. To date, baxdrostat is the only ASI that has received Food and Drug Administration (FDA) approval. (114) Patients should be cautioned about side effects for both agents.(115)

The Work Group systematically reviewed evidence related to this recommendation.(110,111,114) Therefore, it is categorized as Reviewed, Amended. The Work Group’s confidence in the quality of the evidence was low. The body of evidence had some limitations including limited sample sizes, mostly indirect comparisons, and a limited number of randomized trials. The benefits of once-daily spironolactone outweigh the potential harm of adverse events when the patient with RHTN is chosen carefully and monitored closely as therapy is initiated. Amiloride is a potassium-sparing diuretic that can be considered as an alternative to spironolactone, although it must also be used cautiously in those at risk for hyperkalemia, and potassium should be monitored. Patient values and preferences vary somewhat, because some patients prefer non-invasive treatments, while others may find the burden of a fourth antihypertensive agent and its potential side effects to be intolerable. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation

14. For initiation of pharmacological hypertension treatment, there is insufficient evidence to recommend starting combination therapy over monotherapy with sequential addition of another medication to reduce adverse cardiovascular outcomes. (Neither for nor against | Reviewed, Amended)

Discussion

For the treatment of hypertension, there is insufficient evidence to recommend for or against initiating SPCM over initiating monotherapy with the sequential addition of another medication and titrating to effect, particularly in the VA/DOD population using medications that are first-line and FDA-approved. This recommendation differs from other recommendations (i.e., ACC/AHA). The systematic evidence review conducted for this CPG update did not identify any studies that met inclusion criteria; for example, the QUARTET study (116) utilized beta blockers as part of the multi-drug combination, a drug not considered first-line therapy. Neither the MacDonald et al. (2017)(117) nor the Wang et al. (2023)(118) studies compared SPCM directly to monotherapy with sequential addition of medications in the comparator arm. Therefore, these studies could not be included in the evidence review for this VA/DOD guideline, despite SPCM showing benefits for more rapid achievement of blood pressure goals. Providers and patients, after shared discussion, including careful consideration of both potential advantages of lower- dose combination pills (i.e., reduction in the number of pills taken, a simplified regimen, reduction in follow-up visits, increase in adherence and persistence, lower side effect profile, reduction in clinical inertia, reduction in co-payments and possible increase in positive outcomes) and potential disadvantages (i.e., not using medications in the doses found to reduce adverse cardiovascular events in randomized trials) and shared decision making, may decide to consider single pill combination therapy as initial HTN therapy.

After systematically reviewing evidence related to the recommendation, the Work Group’s recommendation was characterized as Reviewed, Amended.(116-118) The body of evidence had limitations including the lack of studies with proper comparators, study design (i.e., no comparisons of initiating combination therapy versus initiating monotherapy with sequential addition of additional drugs), use of non-VA/DOD populations and use of non-FDA approved medications. The confidence in the quality of evidence was very low. Potential benefits (improved adherence, possible morbidity and mortality benefit) were largely balanced with potential harm (general applicability, mildly hypertensive patients requiring therapy, potential for longer duration of non-optimally treated hypertension with stepped care). With respect to patient values and preferences, while studies show that in general, patients will adhere more to single pill therapy than multiple pill therapy, this selection should be tailored to specific patient characteristics such as severity of HTN, feasibility of follow-up frequency, and fear of possible side effects. Some patients may prefer reducing the number of pills, but multi-drug fixed dose single pill combinations may not be available locally. Because this is a Reviewed, Amended recommendation, the Work Group systematically searched for evidence related to the recommendation in the evidence review conducted as part of this guideline update; however, no evidence met inclusion criteria. Therefore, this recommendation is based on evidence cited in the 2014 VA/DOD HTN CPG and is Neither for nor against.

D. Lifestyle Interventions

a. Weight Reduction

Recommendation

15. For individuals with hypertension and co-occurring overweight/obesity, we suggest weight loss to lower blood pressure. (See VA/DOD CPG for Management of Overweight/Obesity) (Weak for | Reviewed, Amended)

Discussion

Yang et al. (2023) in a SR and MA assessed the effect of weight loss on SBP and DBP in patients who have overweight/obesity.(49) The SR and MA included studies in which patients who had overweight/obesity were treated with surgery, medications, or lifestyle interventions (behavior change, nutrition, and physical activity to promote weight loss). They found that SBP and DBP significantly decreased by 5.9 mmHg (95% CI, 3.5-8.0) and 3.4 mmHg (95% CI, 1.9-4.8), respectively, when patients experienced a mean reduction in body mass index (BMI) of 2.3 kg/m². When BMI was decreased by 4.1 kg/m², SBP and DBP further decreased by 6.8 mmHg (95% CI, 5.2-8.1) and 3.7 mmHg (95% CI, 2.0-5.2), respectively. Overall, they found that reductions in BP in patients who had overweight/obesity were more pronounced when their BMI decreased by three or more kg/m². Two other SRs by Basile et al. (2025)(119) and Sibenhofer et al. (2021)(120) also demonstrated that when patients who have overweight/obesity lose weight with medications, SBP and DBP decrease significantly.

The Work Group systematically reviewed evidence related to this recommendation.(49,119,120) Therefore, it is categorized as Reviewed, Amended. The Work Group’s confidence in the quality of the evidence was very low. The body of evidence had significant limitations including high heterogeneity, selection bias, and failure to separate medical interventions (weight loss medication vs. surgery).(49) The benefits of weight loss outweighed the potential harms, as weight loss results in reduction of other morbidities and mortality. Patient values and preferences varied largely because some patients may prefer less invasive methods to lose weight, while others are unable to successfully lose weight through behavior change, nutrition, and physical activity. Some patients also may not qualify for certain medications or surgeries. The Work Group considered other factors such as equity, feasibility, acceptability, and subgroup considerations when forming this recommendation. While behavior change, nutrition, and physical activity are not limited by insurance coverage, some patients may live in areas where access to healthy foods and outdoor space is limited. Medical deserts also pose barriers for some patients to access specialists such as surgeons and therefore may necessitate utilizing other options such as medications for weight loss. Furthermore, for military readiness, Service members may not be eligible for certain medications or procedures. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation

16. In individuals with hypertension and co-occurring overweight/obesity, we recommend

Glucagon-like Peptide 1 (GLP-1) receptor agonist-based medications for weight loss and lowering blood pressure. (See VA/DOD CPG for Management of Overweight/Obesity) (Strong for | Reviewed, New-replaced)

Discussion

Basile et al. (2025) in an SR and meta-analysis reported that patients who had overweight or obesity experienced higher weight loss and associated reduction in SBP and DBP when given Glucagon-like Peptide 1 receptor agonist (GLP-1 RA)-related medications compared to patients given placebo treatment.(119) The study included 82 RCTs (n=80,940) that assessed changes in SBP in addition to weight loss and 75 RCTs (n=72,781) that assessed changes in DBP. Patients who received GLP-1 RA-related medications experienced reduction in SBP by 3.4 mmHg and DBP by 0.9 mmHg. A greater reduction in weight was significantly associated with a greater reduction in BP. Subgroup analysis was also performed to compare single agonist GLP-1 RA- related medications to dual agonists and triple agonists. The authors found that the most significant reduction in BP was associated with dual agonists (SBP -5.1 mmHg; DBP -1.8 mmHg) and triple agonists (SBP -6.6 mmHg; DBP -2.1 mmHg). The strength of the evidence was rated as moderate.

The Work Group systematically reviewed evidence related to this recommendation.(119) Therefore, it is categorized as Reviewed, New-replaced. The Work Group’s confidence in the quality of the evidence was moderate. The body of evidence had some limitations including very high heterogeneity due to studies with smaller sample sizes being included in the analyses. The included studies also lacked long-term follow-up (median follow-up was eight months). The lowest body mass index for inclusion into GLP-1 RA studies was 27. These drugs were investigated primarily for diabetes control and/or weight loss, and blood pressure reduction was an added benefit in secondary analyses. The benefits of utilizing GLP-1 RA-related medications for weight loss and BP reduction outweigh the potential harms. The benefits seen include improved sleep quality in those with sleep apnea, control of diabetes, and overall positive cardiovascular effects. The harms include possible extreme weight loss and disordered eating in some patients resulting in muscle wasting, particularly when protein intake is low or decreases, and when patients are unable to maintain adequate resistance and strength training. There are also known gastrointestinal (GI) side effects such as nausea, diarrhea, constipation, and poor appetite. Patient values and preferences varied somewhat because some patients may prefer less invasive methods to achieve weight loss, while others have attempted lifestyle modifications with no success. In recommending GLP-1 RA-related medications as a means to lose weight with resultant blood pressure decrease, the Work Group considered patient acceptability, equity, subgroup considerations, and feasibility. GLP-1 RA medications are very popular among patients who have overweight or obesity and wish to lose weight efficiently. The effectiveness of these medications in helping patients lose weight has been widely publicized. However, insurance coverage for these medications, which are not available in generic versions, require pre- authorization in the VA and DOD. Pre-authorization for insurance coverage of GLP-1 RAs often requires a documented trial of lifestyle modifications and trial of other weight-loss medications. Some patients end up paying out of pocket for access to these medications as a result. GLP-1 RA medications are also not covered under plans like TRICARE for Life, which are utilized by military retirees and their spouses. As for subgroup considerations, these medications are not recommended for pregnant persons and may impact military readiness if not appropriately titrated. In older patients and those with physical limitations, loss of muscle mass may increase morbidity and mortality by leading to osteoporosis, falls, and subsequent bone fractures. Serious consideration should be given to consulting nutrition and physical therapy and to encourage physical activity when prescribing GLP-1 RAs in elderly patients. Furthermore, injectable GLP-1 RA medications require refrigeration, which may not be available to Service members who frequently train in the field or who are on deployment. For Service members who need to deploy, a waiver is also required. Thus, the Work Group decided upon a Strong for recommendation.

Recommendation

17. In select individuals with hypertension and co-occurring obesity, we suggest referral for evaluation for bariatric surgery for weight loss and lowering blood pressure, depending on patient characteristics and preferences. (See VA/DOD CPG for Management of Overweight/Obesity) (Weak for | Reviewed, Amended)

Discussion

Wang et al. (2021) conducted a systematic review of 19 RCTs and one SR on the effects of weight loss through surgery on blood pressure reduction in patients who had hypertension and co- occurring obesity.(121) The SR demonstrated that patients with mean BMI ranging from 29-56 who underwent bariatric surgery experienced a reduction in SBP by 3.9 mmHg (weighted mean difference[WMD]), DBP by 2.8 mmHg (WMD), and antihypertensive medication use when compared to patients with obesity who received non-surgical interventions (lifestyle modification and/or medications) to achieve weight loss. Surgical interventions assessed included laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, biliopancreatic diversion with duodenal switch, vertical banded gastroplasty, and duodenal-jejunal bypass liner. Patients with obesity who underwent Roux-en-Y gastric bypass experienced the most significant reduction in BP in addition to successful weight loss. Non-surgical treatments for obesity, which were used as comparators, included dieting, weight reducing medications, and behavioral therapy. The evidence base included GLP-1 RAs available within the inclusion dates March 1, 2019, to November 12, 2025, such as exenatide, were compared against surgical intervention in two studies, metformin in one study, and orlistat or sibutramine in three studies. The strength of the evidence from this SR was moderate in favor of surgical intervention in achieving weight loss to lower BP.

The Work Group systematically reviewed evidence related to this recommendation.(121) Therefore, it is categorized as Reviewed, Amended. The Work Group’s confidence in the quality of the evidence was moderate. The body of evidence had some limitations including reporting and attrition bias. The trials were designed as a means for weight loss and reduction in blood pressure was an added benefit in secondary analyses. Some of the studies included in the systematic review did not demonstrate a change in blood pressure despite weight loss, and others had high rates of attrition and loss to follow-up. The benefits of bariatric surgery for weight loss to lower blood pressure slightly outweighed the potential harms, such as post-operative complications and long-term effects of surgery to include malnutrition. Patient values and preferences varied largely because some patients prefer non-invasive treatments while others prefer not to take medications long-term. Other implications that support a Weak for recommendation include equity, acceptability, feasibility, and subgroup considerations. Surgery may not be available at all VA/DOD sites with availability dependent on whether bariatric surgery is offered by the treatment facility or at nearby civilian institutions. Some military hospitals are in rural areas where surgeon capacity is limited. Additionally, patients who do not meet criteria for obesity are not eligible for bariatric surgery as a treatment for weight loss, and Service members are not eligible for bariatric surgery with regard to medical retention standards. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation

18. In individuals with hypertension and co-occurring overweight/obesity, there is insufficient evidence to recommend for or against orlistat or phentermine/topiramate for weight loss and lowering blood pressure. (See VA/DOD CPG for Management of Overweight/Obesity) (Neither for nor against | Reviewed, New-replaced)

Discussion

The evidence for this recommendation came from a Cochrane Review by Siebenhofer et al. (2021)(120), which assessed for weight loss and BP reduction in patients using orlistat and phentermine/topiramate. The authors found that patients taking orlistat or phentermine/topiramate for weight loss also experienced reductions in SBP and DBP compared to those treated with placebo. One SR included in the study assessed findings from four RCTs on orlistat. The median reduction in SBP and DBP were statistically significant, but very modest at 2.7 mmHg and 2.0 mmHg, respectively. However, based on the 2025 VA/DOD Clinical Practice Guideline for The Management of Adult Overweight and Obesity, orlistat treatment did not lead to a clinically significant difference in weight loss compared to lifestyle interventions, leading to a Neither for nor against recommendation.(122) As for phentermine/topiramate, one RCT from one SR demonstrated median reductions in SBP and DBP of 2.0 mmHg and 1.3 mmHg, respectively, for low-dose treatment, and 4.2 mmHg and 2.0 mmHg, respectively, for high-dose treatment. While the 2025 Clinical Practice Guideline for the Management of Adult Overweight and Obesity made a treatment for weight loss, the evidence was rated as low.

The Work Group also reviewed evidence regarding treatment of overweight/obesity with naltrexone/bupropion. While patients in the study experienced a reduction in weight, they did not experience any reduction in BP.(120) Thus, the Work Group did not develop any recommendations for use of this medication combination in this CPG.

The Work Group systematically reviewed evidence related to this recommendation.(120) Therefore, it is categorized as Reviewed, Amended. The Work Group’s confidence in the quality of the evidence was low. The body of evidence had some limitations including bias, imprecision, smaller sample sizes, inconsistent blinding across studies, and lack of long-term outcomes due to attrition bias. The benefits of utilizing these two medications for weight loss and lowering BP are balanced with the potential harms. Another benefit seen includes overall positive cardiovascular effects. The harms include GI side effects that may result in frequent loose stools and loss of electrolytes for orlistat. For the DOD, such side effects are undesirable for Service members training in the field or on deployment and may interfere with maintaining physical fitness. Phentermine/topiramate is associated with emergent cardiovascular events, in a dose-response manner with higher doses increasing risk compared to placebo.(120,123) Phentermine/topiramate also carries twice the risk of suicide compared to placebo.(124) Patient values and preferences varied somewhat, because some patients may prefer less invasive methods to achieve weight loss while others have attempted lifestyle modifications with no success. Patients may be willing to trial phentermine/topiramate as a steppingstone to obtaining insurance authorization and coverage for new medications (GLP-1 RAs). Orlistat and phentermine/topiramate are used to treat overweight/obesity and the evidence was deemed low from the VA/DOD Obesity/Overweight Clinical Practice Guideline. Reductions in blood pressure would be an indirect outcome of effective weight loss. The Work Group considered the following implications: patient acceptability, equity, and subgroup considerations. Medications such as orlistat and phentermine/topiramate have not been as widely accepted and preferred by patients due to their more extensive and undesirable side effect profile compared to effectiveness in promoting weight loss when equated to newer weight loss medications such as GLP-1 RAs. They are also not recommended for patients with certain kidney, heart, and liver conditions. Additionally, the combination of phentermine and topiramate is not recommended for patients at risk of suicide or for pregnant persons. There is also a requirement for women of childbearing age who take phentermine/topiramate to undergo frequent pregnancy testing. These medications are more accessible, as they are typically cheaper and covered by insurance policies for both the VA and DOD, and do not require insurance pre-authorization. However, pharmacies that want to dispense phentermine/topiramate (Qsymia®) must be enrolled in Qsymia Risk Evaluation and Mitigation Strategy (REMS) program to be authorized to dispense the medication. Not all military treatment facilities are enrolled in this program, which means patients will have a copay if they obtain the medication through civilian pharmacies or the Tricare Mail-order Pharmacy. Thus, the Work Group decided upon a Neither for nor against recommendation.

b. Dietary Modifications

Recommendation

19. We recommend a combination of a healthy low-sodium diet with less than 2,300 mg/day of sodium and physical activity greater than 120 minutes/week to improve blood pressure control. (Strong for | Reviewed, New-added)

Discussion

The evidence in support of this recommendation explored combinations of lifestyle interventions to improve blood pressure. The strongest evidence supported a combination of a low sodium diet with sodium less than 2,300 mg/day and physical activity ranging from low intensity (such as walking and yoga) to moderate/high intensity aerobic exercise (such as biking and group exercise programs) to improve blood pressure. Evidence also supported the addition of resistance training in combination with diet and aerobic exercise as an all-inclusive approach to a healthy lifestyle to improve blood pressure.

The current evidence aligned with the previous 2020 VA/DOD HTN CPG, noting that aerobic and resistance exercise interventions, both individually and in combination, have been shown to reduce blood pressure. The evidence reviewed included one SR and nine RCTs. All study participants had HTN. The authors used a variety of lifestyle interventions (LSI) including diet, physical activity (PA), Cognitive Behavioral Therapy (CBT), and mindfulness. The use of the Dietary Approaches to Stop Hypertension (DASH) diet and physical activity was the most common combination. All but one of the research studies including the combination of a low sodium diet and physical activity showed reductions in blood pressure. The one study that did not show a reduction in blood pressure also had participants with the least amount of physical activity. Combinations of a low sodium diet and CBT did show reductions in blood pressure. The combination of a low sodium diet and mindfulness did not show significant changes in blood pressure, the strength of evidence for this was moderate.

Krishnamoorthy et al. (2023)(47) conducted a SR of 14 RCTs on the effects of healthy diet (HD) and physical activity (PA) vs. usual care that showed a reduction in both SBP and DBP. RCTs by Unda Villafuerte et al. (2024)(125), Blumenthal et al. (2021)(126), Hinderliter et al. (2021)(127), and Sayon-Orea et al. (2019)(128) all noted an improvement in SBP compared to the control group. Unda Villafuerte et al. (2024)(125), Blumenthal et al. (2021)(126), and Hinderliter et al. 2021(126) were all able to demonstrate a significant improvement in DBP for subjects receiving multicomponent lifestyle interventions vs. usual care.

PA in the current research reviewed varied in amount, type, and intensity. The 2020 VA/DOD HTN CPG concluded that “aerobic and resistance exercise interventions, both individually and in combination, have been shown to reduce blood pressure.”(129) We recommend including resistance training into PA recommendations along with aerobic exercise to improve blood pressure control. An umbrella review by Pescatello et al. (2021)(48) demonstrated that participating in PA reduced blood pressure among adults with HTN as well as those with normal BP, and those that were diagnosed with pre-hypertension. The umbrella review comprised 15 meta-analyses that assessed PA in adults with HTN, six of which found the greatest reduction in BP occurred in adults with diagnosed hypertension. PA included low- to vigorous-intensity activities. Five MAs assessed aerobic exercise, three MAs assessed resistance training, and one MA assessed combined aerobic and resistance training and its effects on BP. PA was shown to reduce systolic BP by 5 to 17 mmHg (in 13 studies) and diastolic BP by 2 to 10 mmHg (in 14 studies) compared to no PA. By category: aerobic exercise reduced SBP by 8.3 mmHg and 5.2 mmHg on average (5 MAs); resistance training reduced SBP by 5.3 mmHg and 5.2 mmHg on average (3 MAs); aerobic and resistance training together reduced SBP by 5.3 mmHg and DBP by 5.6 mmHg (1 MA). The strength of the evidence was rated as very low for PA alone. HTN is the leading modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD) morbidity in the U.S., and PA and HD provide improved mood, mental health, sleep and overall well-being. PA >120 min/week at some intensity level, either low impact, moderate, high or a combination of intensities with resistance training, was achievable regardless of conditioning level. PA would also increase military readiness in our Service members.

DASH diet with group CBT (126) led to significant improvement in SBP compared to usual care control, mean change for intervention at four months: 16.1 (95% CI, -13.0 to 19.2), mean change for control: -3.4; (95% CI, -0.4 to -6.4); p<0.001. Throughout the evidence, the DASH diet was most effective for reducing sodium intake. It is recommended that the provider and patients work through shared decision making to include diet and PA recommendations, and to include the optional referral to a dietitian to support diet education. DASH or DASH + CBT led to greater reduction in 10-year risk of CVD events and lifetime risk of CV death compared to usual care but did not differ from one another. One SR (47) reported significant SBP improvement compared to usual care control in an MA with 6 RCTs: MD: -9.9 (95% CI, -13.3 to -6.4); p<0.05. RCTs by Unda

Villafuerte et al. (2024)(p<0.001)(125), Blumenthal et al. (2021)(p=0.005)(126), and Sayon-Orea et al. (2019)(p<0.001)(128) all reported significant decreases in SBP for diet + exercise compared to control.

Several organizations recommend or suggest targets for daily sodium intake. The AHA recommends no more than 2,300 mg of sodium a day. Both the AHA and the ACC recommend the ideal limit is no more than 1,500 mg/day for most adults, especially for those with high blood pressure. However, sodium intake lower than 2,300 mg/day may be harmful for patients with heart failure.(130) Notably, sodium restriction can result in poor dietary quality with inadequate macronutrient and micronutrient intake which has been associated with clinical instability. The ACC does not endorse a specific sodium threshold for heart failure patients and instead uses the language of “avoiding excessive sodium intake” rather than prescribing a strict numerical target. The average daily sodium intake in the U.S. is over 3,400 mg/day excluding table salt, well above this guideline’s recommendation of 2,300 mg/day.(131) Disagreement regarding the exact cut- point at which risks outweigh benefits should not distract from a unified public health message that a reduction in sodium intake from current levels is desirable. Benefits of sodium reduction and PA included improvements in CVD biomarkers, mood, insulin sensitivity, and other comorbidities. A combination of a healthy lifestyle and group physical activities also reduced loneliness in patients who participated in group physical activities and is a key proponent in supporting activity duty readiness.

The Work Group systematically reviewed evidence related to this recommendation.(47,125) Therefore, it is categorized as Reviewed, New added. The Work Group’s confidence in the quality of the evidence was moderate. The body of evidence had some limitations including randomization inconsistencies, allocation concealment and blinding of patients, standardization of study personnel and assessors, lack of intention-to-treat analysis and high attrition. There were also limitations with broad sampling that included patients with normal BP, pre-hypertension, and hypertension.(48) The studies included in this umbrella review also did not uniformly stratify data by age, sex, socioeconomic status, intensity/duration/frequency of exercise nor body mass index, all of which could be effect modifiers. The previous related recommendations in 2014 and 2020 noted the benefits of improved SBP, DBP and comorbidities from a low-sodium diet with PA, as well as benefits to readiness of active-duty personnel, which outweigh the potential harm. A risk of participating in PA is musculoskeletal injury if patients are deconditioned and begin higher intensity activities too quickly. Additionally, risk of sodium reduction is potentially harmful to cardiovascular outcomes if intake is reduced to below recommended levels. However, some patients may dislike a low-sodium diet and/or dislike or have limited ability to exercise, so the Work Group determined that there is some variation in patient values and preferences with regards to participating in PA. Participating in PA requires time commitment, which may not be feasible for patients with multiple jobs or family obligations. Patients with disabilities and certain medical conditions may also be limited in their ability to participate in PA. Findings from the VA/DOD patient focus group concluded that participants desire alternatives to medications. They value an individualized approach to the treatment of their hypertension and would prefer to focus on LSIs including dietary changes. Other implications that were assessed included equity, feasibility, and subgroup considerations. There are a wide variety of resources that can assist patients in getting started with increasing PA and diet changes such as books, internet classes, free community classes, mobile applications, and handouts from medical professionals can also be accessed with little to no cost. Furthermore, PA is a core requirement for fitness for duty and military readiness for Service members. While there may be some barriers to exercising outside (e.g., safety concerns or lack of parks nearby), there are many opportunities to engage in indoor exercise with little to no equipment depending on the patient’s resources and preferences. Thus, the Work Group decided upon a Strong for recommendation.

E. Procedural Interventions

Recommendation

20. In individuals with hypertension and co-occurring renal artery stenosis, we recommend pharmacotherapy over renal artery angioplasty or stenting. (Strong for | Reviewed, New-added)

Discussion

A meta-analysis that included eight randomized (or quasi-randomized) controlled trials consisting of 2,444 participants was reviewed. This study included individuals greater than 18 years old, with hypertension (diastolic BP >95 mmHg and significant atherosclerotic renal artery stenosis [unilateral or bilateral reduction in luminal diameter of >50%]). Patients with fibromuscular dysplasia, total occlusion of the renal artery, an affected kidney size of less than eight centimeters, malignant hypertension, or a serum creatinine >500 mol/L (>5.66 mg/dL) were excluded. The trials compared either balloon angioplasty (with or without stent insertion) to medical therapy. Overall results demonstrated that intervention with angioplasty/stent was not associated with an improvement in SBP (-1.1, 95% CI, 3.4 – 1.2 mmHg); cardiovascular outcomes (OR [odds ratio] 0.9 [95% CI, 0.7 – 1.1]), renal adverse outcomes (OR 0.9 [95% CI, 0.7 – 1.3]), or serum creatinine at 2 years (MD -6.5 µmol/L [95% CI, -19.5 to 6.5 µmol/L)(MD -0.07 mg/dL [95% CI, -0.2 to 0.07 mg/dL]). There was a reduction in DBP at 2 years or end of follow-up (n=869) of -1.8 mmHg, (95% CI, -3.5 to -0.2) and a small reduction in antihypertensive medications (n=1,777) -0.2 (95% CI, - 0.3 to -0.04).(132) Medical therapy should be similar to that used in the two pivotal randomized controlled trials. For the CORAL study, medical therapy included an angiotensin II receptor blocker with or without hydrochlorothiazide and the combination of amlodipine-atorvastatin with a target BP of less than 140/90 mmHg in patients without coexisting conditions and less than 130/80 mmHg in those with diabetes or CKD.(133) In the ASTRAL trial, therapy consisted of statins, antiplatelet agents and optimal blood-pressure control.(134)

Adverse events were inconsistently defined and reported across studies. Periprocedural deaths occurred in 4 of 839 individuals (0.5%) across three trials.(133-135) Other uncommon adverse events included pseudoaneurysms, distal embolization, groin hematoma, bleeding requiring transfusion, acute kidney injury and renal artery occlusion with a combined event rate of less than 3.2% across four RCTs.(133-136)

The CORAL and ASTRAL trials found no difference in outcomes by severity of CKD at baseline or severity of renal artery stenosis.(133,134) The CORAL trial found no interaction between treatment group and the following characteristics: sex, Black race, or diabetes.(133)

Based on the relevant studies reviewed in the current CPG evidence base, in patients with hypertension and renal artery stenosis, we recommend medical therapy over angioplasty or stenting. The Work Group reviewed related evidence; therefore, this recommendation is Reviewed, New-added. The body of evidence had some limitations including small sample size, lack of power for clinically significant outcomes, and limited inclusion criteria.(132) The evidence review did not include individuals with fibromuscular dysplasia, flash pulmonary edema or acute decompensation (rapidly worsening kidney disease), single functioning kidney, or severe/difficult- to-control hypertension. The strength of evidence was rated as low or very low depending on the outcome. The benefits of medical therapy over angioplasty/stenting for cardiovascular, renal outcomes and SBP were similar, and were balanced with the potential harm of periprocedural death and other complications which were small. Patient values and preferences were similar because while most patients would prefer medical therapy, some may prefer the other intervention. Thus, the Work Group decided upon a Strong for medical therapy recommendation. Patients with renal artery stenosis should undergo a trial of medical therapy over intervention/stenting given the similar clinical outcomes and small but known risks of the intervention.

Recommendation

21. In select individuals with resistant or uncontrolled hypertension, who have an estimated glomerular filtration rate (eGFR) above 40 mL/min/1.73m², we suggest renal artery denervation to lower blood pressure, depending on patient characteristics and preferences. (Weak for | Reviewed, New-added)

Discussion

A meta-analysis(132) consisting of 13 randomized controlled trials involving 2,478 participants was identified as part of the evidence review. This meta-analysis compared the effect of renal nerve denervation (RDN) versus sham therapy on blood pressure. The meta-analysis identified three methods for nerve ablation (radiofrequency, ultrasound, and alcohol-mediated), all of which were included. The median duration to the primary endpoint assessment was three months (range 2-6 months). Overall RDN compared to sham procedure reduced both 24-hour ambulatory SBP and DBP by 4.4 mmHg (95% CI, 2.7- 6.1) and 2.6 mmHg (95% CI, 1.5 - 3.6), respectively. Office SBP and DBP was also reduced with intervention compared to sham (SBP -6.6; 95% CI, -9.7 – 3.7); (DBP -3.5; 95% CI, -5.4 – -1.6).

The meta-analysis attempted to evaluate the long-term BP associated with RDN compared to sham. In the primary studies evaluating long term outcomes (i.e. greater than six months), the patients were unblinded, medication changes were permitted, and crossover from the sham control to the intervention group was permitted. Duration of the follow-up ranged from 6 months to 36 months. RDN reduced both 24 hour and office SBP, -5.4 mmHg (95% CI, -7.8 to -3.1) and -6.9 mmHg (95% CI, -11.2 to -2.7), respectively. DBP was not reported.

There was no difference between trials that included those with or without concomitant antihypertensive medications (–4.8 mmHg; 95% CI, –7.7 to –2.0; P=0.001; I²=79% versus –4.0 mmHg; 95% CI, –5.7 to –2.3; P<0.00001; I²=32%, respectively; P for interaction, 0.62).

There was also no interaction between the method (radiofrequency, ultrasound or alcohol- mediated) of RDN used and any measure of blood pressure, but this was likely an underpowered comparison.

There were no safety differences between RDN and sham. Adverse events assessed included all- cause death, embolic event, stroke, vascular complication, renal artery stenosis, hypertensive crisis and hospitalization for heart failure.

There are several limitations, including little information on BP control after six months and no information on clinical outcomes (e.g., myocardial infarction, stroke, etc.). The studies were conducted in large referral centers with a high volume of procedures. It is unclear if this experience will be generalizable to smaller facilities or those with limited procedure experience. Most trials excluded those with an eGFR <40 – 45 mL/min/1.73m² and those age >75-80.

Another meta-analysis evaluated RDN(137) for the treatment of resistant hypertension. This study included 24 randomized controlled trials that compared RDN with either sham procedure or standard-of-care treatment. They only included studies that enrolled patients with resistant hypertension (the paper doesn’t define how they operationally defined resistant hypertension). Treatment duration varied from eight weeks to 48 months.

The only outcome assessed was blood pressure and serum creatinine. Overall SBP was reduced (measured in various ways) by 3.5 mmHg (95% CI, -1.1 to -5.9) and DBP was reduced (measured in various ways) by 3.3 mmHg (95% CI, -1.3 to -5.3). Only three studies reported on changes in serum creatinine. There was no difference in serum creatinine at the end of these studies (MD - 2.5 µmol/L (95% CI, -7.9 to -2.9 µmol/L).

The Work Group systematically reviewed evidence related to this recommendation (132,137) identified through the systematic evidence review. Therefore, it is categorized as Reviewed, New- added. The Work Group’s confidence in the quality of the evidence was low. The body of evidence had some limitations including small sample size, underpowered to identify differences in RDN modality, lack of clinical outcomes, limited duration of follow-up, and a lack of subgroup analyses. The benefits of RDN included improved SBP and DBP both in all comers, and in those with resistant hypertension, and slightly outweighed sham therapy given the limited reported adverse outcomes associated with RDN. Patient values and preferences are likely somewhat varied, because some patients may prefer a procedure over medical therapy for adverse effects, or because of the number of BP medications they are prescribed (i.e. resistant hypertension). Thus, the Work Group decided upon a Weak for recommendation.

X. Research Priorities

During the development of the 2026 VA/DOD Hypertension CPG, the Work Group identified topics needing additional research, including areas requiring stronger evidence to support current recommendations and research exploring new areas to guide future CPG updates.

A. Monitoring

Further research evaluating clinical outcomes, specifically cardiovascular outcomes, based on treatment to home blood pressure goals, is needed to support HBPM. Evaluation of the cost- benefit for providing HBPM to Veterans and active-duty Service members, with a specific focus on the potential long-term cost vs. benefit of better blood pressure control throughout the entire health-care enterprise, should be explored. Studies should also be done to assess barriers on the implementation of AOBP, as adoption has been limited.

B. Blood Pressure Goals

Future research should prioritize identifying the most promising population(s) for more intensive SBP lowering and whether even lower SBP targets (<120 mmHg) are more beneficial as compared with a SBP goal of <130 mmHg. Additionally, research should consider age specifics for goals given the large age span across the active-duty DOD to VA patient population, considering those who are elderly, frail, and possibly unable to tolerate a more intensive target. Further clinical trials should also explore exclusively enrolling individuals with an elevated DBP > 90mmHg.

C. Pharmacotherapy

Future studies should explore outcome data in those with resistant hypertension, as they are at increased risk for cardiovascular events, to inform clinicians on which fourth-line drug will have the greatest impact on cardiovascular events. Research should also be conducted on the impact of age, sex, and comorbidities like diabetes, CKD, coronary artery disease (CAD), or prior stroke on the response to specific medications in patients with resistant hypertension.

Head-to-head comparisons of alternative agents are needed, including aprocitentan and baxdrostat, as well as RCTs that evaluate the safety and efficacy of stepped therapy versus multidrug combination single-pill medication using FDA-approved medications in VA/DOD or similar populations. Additionally, robust head-to-head comparisons evaluating within-medication- class differences, including differences in age, hypertension stage, comorbidities, morbidity, and mortality, and pharmacogenetics to aid in identifying responders, would be beneficial.

D. Lifestyle Interventions

Future research in this space should stratify the effects of physical activity on BP by frequency, intensity, and duration of exercise, including the use of cardiac rehabilitation or other group exercise classes provided by trained personnel. Socioeconomic status of the sample population should be explored to provide more insight into equity, feasibility, and subgroup considerations. Additionally, research on smoking and alcohol cessation and how it impacts blood pressure should be done using bio-verification vs. self-reporting.

E. Other Treatment Modalities

Future research should explore healthcare professional-led interventions to manage blood pressure. Studies should evaluate the cost-effectiveness of pharmacist-led interventions for hypertension, given their resource-use implications. Dietitian-led interventions should also be evaluated, focusing on the intensity and duration of the intervention types that are most effective for improving blood pressure control. Additionally, more research is needed to evaluate the effectiveness of nurse-led interventions to manage hypertension across specific subgroups (e.g., age, ethnicity, comorbidities) and to explore the effectiveness of nurse-led interventions that include initiation and titration of antihypertensive medications using established protocols.

Further research is needed to explore long-term comparisons between incretin-based therapies and bariatric surgery, as well as adherence differences with various weight loss medications, to include GLP-1 receptor agonists, and assess the long-term effects of these medications and the sustainability of desired outcomes in patients.

Additionally, some populations remain unstudied regarding renal artery stenosis (RAS), including those with fibromuscular dysplasia or those with recurrent hospitalizations for volume issues; these should be objectives for future research. In these patients, it may be reasonable to attempt intervention for RAS or involve them in future clinical trials. Future research should also evaluate the long-term effects of renal artery denervation on blood pressure, as well as its impact on clinical outcomes. Lastly, future research should include continued research with new and emerging digital health technologies to include artificial intelligence integration/assistance, synchronous versus asynchronous modalities, and explore demographic preferences in relation to digital health technology uptake.

Appendix A: Guideline Development Methodology

A. Developing Key Questions to Guide the Systematic Evidence Review

To guide this CPG’s systematic evidence review, the Work Group drafted 12 KQs on clinical topics of the highest priority for the VA and DOD populations. The KQs followed the population, intervention, comparison, outcome, timing, and setting (PICOTS) framework, as established by AHRQ (see Table A‐1).

Table A-1. PICOTS (138)

Abbreviations: PICOTS—population, intervention, comparison, outcome, timing, and setting

The Champions, Work Group, and Evidence Review Team carried out several iterations of this process, each time narrowing the scope of the CPG and literature review by prioritizing the topics of interest. Due to resource constraints, not all developed KQs could be included in the systematic evidence review. Thus, the Champions and Work Group determined which questions were of highest priority to include in the review. Table A-2 contains the final set of KQs used to guide the systematic evidence review for this CPG.

Using the GRADE approach, the Work Group rated each outcome on a 1–9 scale (7–9, critical for decision making; 4–6, important, but not critical, for decision making; and 1–3, of limited importance for decision making). Critical and important outcomes were included in the evidence review (see Outcomes); however, only critical outcomes were used to determine the overall quality of evidence (see Determining Recommendation Strength and Direction).

a. Population(s)

The clinical population considered in this systematic review are adults (aged 18 years or older) with hypertension. Individual KQs have additional specific criteria noted below:

• KQ1: Adults with hypertension or suspected to have hypertension.
• KQ3: Adults with hypertension and co-occurring obesity/overweight.
• KQs 5 and 6: In addition to the standard population, patients with established CV disease or high CV risk; age groups, especially older adults >80 years of age; patients with diabetes mellitus; patients with CKD defined as eGFR <60.
• KQ9: Adults with resistant or difficult-to-control hypertension.

b. Interventions and Comparators

Abbreviations: AA: aldosterone antagonist; ACEI: angiotensin converting enzyme inhibitor; AOBP: automated office blood pressure; APP: advanced practice provider; ARB: angiotensin II receptor blockers; BB: beta blocker; BP: blood pressure; CCB: calcium channel blocker; CLI: comprehensive lifestyle intervention; DASH: dietary approaches to stop hypertension; DHP: dihydropyridine; FDA: Food and Drug Administration; GLP-1: Glucagon-like peptide-1; HCTZ: hydrochlorothiazide; HTN: hypertension; KQ: key question; MRA: mineralocorticoid receptor antagonist; RN: registered nurse; SGLT2i: sodium-glucose cotransporter 2 inhibitors

c. Outcomes

Abbreviations: AUC: area under the curve; BP: blood pressure; CV: cardiovascular; HTN: hypertension; MI: myocardial infarction; MPR: medication possession ratio; NPV: negative predictive value; PDC: proportion of days covered; PPV: positive predictive value

d. Timing

e. Setting(s)

The standard setting for KQs 1-11 is Ambulatory (outpatient) care; KQ 12 will include Ambulatory outpatient and inpatient care.

B. Conducting the Systematic Review

Literature searches identified 15,138 citations potentially addressing the KQs of interest for this evidence review. Of these, 13,031 were excluded upon title/abstract review for lack of relevance to the CPG topic, not being published in English, or publication prior to the inclusion date. A total of 2,107 full-length articles were reviewed. Of these, 2,012 were excluded for the following reasons: intervention not of interest (342), outcomes not of interest (318), comparator not of interest (282), publication type not of interest (248), population not of interest (247), superseded by another SR (162), study design not of interest (143), not of very high HDI (64), does not address any KQ (45), included in an included SR (40), meta-analysis not performed (36), other (36), inadequate sample size (14), included studies not of very high HDI (14), relevant studies published prior to March 1, 2019 (10), not English language (9), and duplicate (2). Detailed information on inclusions and exclusions throughout the review process are provided in Figure A-1 below.

Overall, 95 publications addressed one or more KQs and were considered as evidence in this review, including 46 systematic reviews and 49 primary studies. Table A-2 indicates the number of studies that addressed each of the questions, with some publications being used for more than one KQ.

Figure A-1. Study Flow Diagram

The alt text for the Study Flow Diagram is

Abbreviations: HDI: human developmental index; KQ: key question; RCT: randomized control trial; SR: systematic review

Alternative Text Description of Study Flow Diagram

Figure A-1. Study Flow Diagram is a flow chart with nine labeled boxes linked by arrows that describe the literature review inclusion-exclusion process. Arrows point down to boxes that describe the next literature review step and arrows point right to boxes that describe the excluded citations at each step (including the reasons for exclusion and the numbers of excluded citations).

1. Box 1: 15,365 citations identified by searches.

a. Right to Box 2: 227 citations excluded as duplicates.

b. Down to box 3.

2. Box 3: 15,138 abstracts reviewed.

a. Right to Box 4: 13,031 citations excluded at the abstract level. Citations excluded were off topic, not published in English, or published prior to inclusion date.

b. Down to Box 5.

3. Box 5: 2,107 full-length articles reviewed.

a. Right to Box 6: 2,012 citations excluded at full-article level.

i. 342 interventions not of interest.

ii. 318 outcomes not of interest.

iii. 282 comparators not of interest.

iv. 248 publication type not of interest.

v. 247 population not of interest.

vi. 162 superseded by another SR.

vii. 143 study design not of interest.

viii. 64 not of very high HDI.

ix. 45 does not address any KQ.

x. 40 included in an SR.

xi. 36 meta-analysis not performed.

xii. 36 other.

xiii. 14 inadequate sample size.

xiv. 10 relevant studies published prior to March 1, 2019.

xv. 9 not English language.

xvi. 2 duplicates.

b. Down to Box 7.

4. Box 7: 95 included publications (46 systematic reviews and 49 primary studies).

Table A-2. Evidence Base for KQs

ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; CAD: coronary artery disease; CCB: calcium channel blocker; CKD: chronic kidney disease; CVD: cardiovascular disease; DM: diabetes mellitus; KQ: key question; LVH: left ventricular hypertrophy; NMA: network meta-analysis; RCT: randomized controlled trial; SR: systematic review

a. General Criteria for Inclusion in Systematic Evidence Review

• Randomized controlled trials (RCTs) or SRs of RCTs published on or after March 1, 2019, to November 12, 2025.
• Studies must have been published in English.
• Publication must have been a full clinical study or SR; abstracts alone were not included. Similarly, letters, editorials, research protocols, and other publications that were not full- length clinical studies were not accepted as evidence.
• Systematic reviews must have searched MEDLINE or EMBASE for eligible publications, performed a risk of bias assessment of included studies, and assessed the quality of evidence using a recognizable rating system, such as GRADE or something compatible (e.g., the one used by the AHRQ Evidence-based Practice Centers [EPCs]). If an existing review did not assess the overall quality of the evidence, evidence from the review was reported in a manner that allowed us to judge the overall risk of bias, consistency, directness, and precision of evidence. We did not use an existing review as evidence if we were not able to assess the overall quality of the evidence in the review. If multiple SRs addressed a KQ, we selected the most recent and/or comprehensive review. In many cases, we used multiple SRs to address a single KQ, as each SR dealt with a different intervention or intervention-comparator combination.
• RCTs must have had an independent control group. Randomized crossover trials were only included if data from the first period (prior to treatment crossover) was reported separately or an adequate washout period was used.
• For KQ 1, diagnostic accuracy studies and SRs of diagnostic accuracy were included. For KQ 3 (weight loss), RCTs with pre-planned subgroup analyses, observational studies and SRs of observational studies that report on groups who did and did not lose weight were used to address the KQ. For all other KQs, only SRs of RCTs and individual RCTs were considered.
• Study must have enrolled at least 20 patients (10 per study group for RCTs and 20 for observational studies).
• Study must have enrolled at least 85% of patients who meet the study population criteria. If the patient population fell below this threshold but the relevant population of patients was reported separately, then that study was included.
• To ensure applicability to the VA/DOD healthcare systems, and ensure consistency across the CPG program, inclusion of individual studies was limited to very high Human Development Index (HDI), countries with an index ≥0.8 where standards of healthcare are comparable (e.g., United States, Canada, United Kingdom, Western Europe, Israel, Japan, Hong Kong, Australia, and New Zealand). Inclusion of the systematic reviews was limited to those including more than half of the studies from eligible regions.

o These regions of interest are listed in Table 1 of the Statistical Annex of the

2023/24 Human Development Report produced by the United Nations Development Program.

• Study must have reported on at least one outcome of interest.

b. Literature Search Strategy

Information regarding the bibliographic databases, date limits, and platform/provider can be found in Table A-3, below. Additional information on the search strategies, including topic-specific search terms and search strategies can be found in Appendix F. In accordance with VA/DOD CPG methodology, evidence retrieved in prior VA/DOD systematic reviews for this topic (undertaken before the date limits noted in Table A-3) and summarized in earlier evidence reports can be brought forward to support recommendations categorized as “Not Reviewed, Not Changed” or “Reviewed, Not Changed.” See Appendix C for more information on recommendation categorization.

Table A-3. Bibliographic Database Information

c. Rating the Quality of Individual Studies and the Body of Evidence

Sigma Health Consulting assessed the methodological risk of bias of individual diagnostic, observational, and interventional studies using the USPSTF method. Each study is assigned a rating of Good, Fair, or Poor based on a set of criteria that vary depending on study design. Detailed lists of criteria and definitions appear in Appendix VI of the USPSTF procedure manual.(36)

Next, Sigma Health Consulting assessed the overall quality of the body of evidence for each critical and important outcome using the GRADE approach. This approach considers the following factors: overall study quality (or overall risk of bias or study limitations), consistency of evidence, directness of evidence, and precision of evidence. The overall quality of the body of evidence is rated as High, Moderate, Low, and Very Low.

C. Developing Evidence-Based Recommendations

In consultation with the VA Office of Quality and Patient Safety and the Clinical Quality Improvement Program, Defense Health Agency, and Sigma Health Consulting convened a 3.5 day in-person recommendation development meeting from February 23-27, 2026, to develop this

CPG’s evidence-based recommendations. Two weeks before the meeting, Sigma Health Consulting finalized the systematic evidence review and distributed the report to the Work Group; findings were also presented during the recommendation development meeting.

Led by the Champions, the Work Group interpreted the systematic evidence review’s findings and developed this CPG’s recommendations. The strength and direction of each recommendation were determined by assessing the quality of the overall evidence base, the associated benefits and harms, patient values and preferences, and other implications (see Determining Recommendation Strength and Direction).

a. Determining Recommendation Strength and Direction

Per 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 (32):

1. Confidence in the Quality of the Evidence

Confidence in the quality of the evidence reflects the quality of the evidence base and the certainty in that evidence. This second domain reflects the methodological quality of the studies for each outcome variable. In general, the strength of recommendation follows the level of evidence, but not always, as other domains may increase or decrease their strength. The evidence review used for the development of recommendations for hypertension diagnosis and management, conducted by Sigma Health Consulting, assessed the confidence in the quality of the evidence base and assigned a rate of “High,” “Moderate,” “Low,” or “Very low.”

The elements that go into the confidence in the quality of the evidence include:

• Is there high or moderate quality evidence that answers this question?
• What is the overall certainty of this evidence?

2. Balance of Desirable and Undesirable Outcomes

Balance of desirable and undesirable outcomes refers to the size of anticipated benefits (e.g., increased longevity, reduction in morbid event, resolution of symptoms, improved quality of life, decreased resource use) and harms (e.g., decreased longevity, immediate serious complications, adverse event, impaired quality of life, increased resource use, inconvenience/hassle) relative to each other. This domain is based on the understanding that most providers will offer patients therapeutic or preventive measures if the advantages of the intervention exceed the risks and adverse effects. The certainty or uncertainty of the provider about the risk-benefit balance will greatly influence the strength of the recommendation.

Some of the discussion questions that fall under this domain include:

• 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?

3. Patient Values and Preferences

“Patient values and preferences” is an overarching term that includes patients’ perspectives, beliefs, expectations, and goals for health and life. More precisely, it refers to the processes that individuals use in considering the potential benefits, harms, costs, limitations, and inconvenience of the therapeutic or preventive measures in relation to one another. For some, the term “values” has the closest connotation to these processes. For others, the connotation of “preferences” best captures the notion of choice. In general, values and preferences increase the strength of the recommendation when there is high concordance and decrease it when there is great variability. In a situation in which the balance of benefits and risks are uncertain, eliciting the values and preferences of patients and empowering them and their surrogates to make decisions consistent with their goals of care becomes even more important. A recommendation can be described as having “similar values,” “some variation,” or “large variation” in typical values and preferences between patients and the larger populations of interest.

Some of the discussion questions that fall under the purview of values and preferences include:

• 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?

4. Other Implications

Other implications consider the practicality of the recommendation, including resources use, equity, acceptability, feasibility and subgroup considerations. Resource use is related to the uncertainty around the cost-effectiveness of a therapeutic or preventive measure. For example, statin use in the frail elderly and others with multiple co-occurring conditions might not be effective and depending on the societal benchmark for willingness to pay, might not be a good use of resources. Equity, acceptability, feasibility, and subgroup considerations require similar judgments around the practicality of the recommendation.

The framework below (Table A-4) was used by the Work Group to guide discussions on each domain.

Table A-4. GRADE Evidence to Recommendation Framework

D. Recommendation Categorization

1. Recommendation Categories and Definitions

For use in the 2026 Hypertension CPG, a set of recommendation categories was adapted from those used by the U ’s NICE.(37,38) These categories, along with their corresponding definitions, were used to account for the various ways in which recommendations could have been updated from the 2020 VA/DOD Hypertension CPG. A summary of the recommendation categories and definitions is available in Table 4.

2. Categorizing Recommendations with an Updated Review of the Evidence

Recommendations were first categorized by whether they were based on an updated review of the evidence. If evidence had been reviewed, recommendations were categorized as “New added,” “New-replaced,” “Not changed,” “Amended,” or “Deleted.”

“Reviewed, New-added” recommendations were original, new recommendations that were not in the 2020 Hypertension CPG. “Reviewed, New-replaced” recommendations were in the previous version VA/DOD Clinical Practice Guideline on Diagnosis and Management of Hypertension guideline but were modified to align with the updated review of the evidence. These recommendations could have also included clinically significant changes to the previous version.

Recommendations categorized as “Reviewed, Not changed” were carried forward from the previous version of the CPG unchanged.

Recommendations could have also been designated “Reviewed, Deleted.” These were recommendations from the previous version of the CPG that were not brought forward to the updated guideline after review of the evidence. This occurred if the evidence supporting the recommendations was out of date, to the extent that there was no longer any basis to recommend a particular course of care and/or new evidence suggests a shift in care, rendering recommendations in the previous version of the guideline obsolete.

3. Categorizing Recommendations without an Updated Review of the Evidence

There were also cases in which it was necessary to carry forward recommendations from the previous version of the CPG without a review of the evidence. Due to time and budget constraints, the update of the Hypertension CPG could not review all available evidence on hypertension diagnosis and management but instead focused its KQs on new or updated scientific research or areas that were not previously covered in the CPG.

For areas of research that have not changed, and for which recommendations made in the previous version of the guideline were still relevant, recommendations could have been carried forward to the updated guideline without an updated review of the evidence. The support for these recommendations in the updated CPG was thus also carried forward from the previous version of the CPG. These recommendations were categorized as “Not reviewed.” If evidence had not been reviewed, recommendations could have been categorized as “Not changed,” Amended,” or “Deleted.”

“Not reviewed, Not changed” recommendations refer to recommendations from the previous version of the Hypertension CPG that were carried forward unchanged to the updated version. The category of “Not reviewed, Amended” was used to designate recommendations which were modified from the 2020 VA/DOD Hypertension CPG with the updated GRADE language, as explained above.

Recommendations could also have been categorized as “Not reviewed, Deleted” if they were determined to be out of scope. A recommendation was out of scope if it pertained to a topic (e.g., population, care setting, treatment, condition) outside of the scope for the updated CPG as defined by the Work Group.

The categories for the recommendations included in the 2026 version of the guideline are noted under the Recommendations. The categories for the recommendations from the 2020 VA/DOD Hypertension CPG are noted in Appendix C.

E. Drafting and Finalizing the Guideline

Following the face-to-face meeting, the Champions and Work Group members were given writing assignments to craft discussion sections to support each of the new recommendations. The Work Group also created tables, appendices, and other sections for inclusion in the 2026 VA/DOD

Hypertension CPG for inclusion. During this time, the Champions and Work Group also updated the algorithm.

After developing the initial draft of the CPG, an iterative review process was used to solicit feedback on and revise the CPG. Once they were developed, the first two drafts of the CPG were posted on the Hypertension Wiki Website for a period of 14-20 business days for internal review and comment by the Work Group. All feedback submitted during each review period was reviewed and discussed by the Work Group, and appropriate revisions were made to the CPG. Following the Draft 3 review and comment period, the Work Group reviewed external feedback and created a final draft of the CPG.

Appendix B: Evidence Table

Table B-1. 2026 Hypertension Evidence Table a, b, c, d

a 2020 Strength of Recommendation column: “N/A” indicates that the 202 VA/D D Hypertension recommendation was a new recommendation and therefore, does not have an associated 2020 strength of recommendation. b Evidence column: The first set of references listed in each row in the evidence column constitutes the evidence base for the recommendation. To be included in the evidence base for a recommendation, a reference needed to be identified through a systematic evidence review carried out as part of the initial development or update of this CPG. The second set of references in the evidence column (called “Additional References”) includes references that provide additional information related to the recommendation, but which were not identified through a systematic evidence review. These references were, therefore, not included in the evidence base for the recommendation and did not influence the strength and direction of the recommendation. c 2026 Strength of Recommendation column: The 2026 VA/DOD Hypertension CPG was developed using the GRADE approach to determine the strength of each recommendation. Refer to the Grading Recommendations section for more information. d Recommendation Category column: Refer to the Recommendation Categorization section for more information on the description of the categorization process and the definition of each category

Appendix C: 2020 Recommendation Categorization

¹ The 2020 Recommendation Text column contains the wording of each recommendation from the 2020 VA/DOD Hypertension CPG. ² The Recommendation Category column indicates the way in which each 2020 VA/DOD Hypertension CPG recommendation was updated. ³ For recommendations that were carried forward to the 2026 VA/DOD Hypertension CPG, this column indicates the new recommendation(s) to which they correspond.

Appendix D: Participant List

John Blickle, MD Chief Fellow, Cardiovascular Diseases Fellowship National Capital Consortium, Walter Reed National Military Medical Center Bethesda, MD Juhyun Cho, FNP-BC Battalion Surgeon, 1-78 Fired Artillery Battalion, 428 Field Artillery Brigade, Fires Center of Excellence Fort Still, OK

Kayla Jones, PT, DPT, CCS Cardiovascular and Pulmonary Clinical Specialist, Ann Arbor VA Ann Arbor, MI Karla Krasnoselsky, MSC, USN PT, DPT,OCS Chief Assistant to Director, Maritime Headquarters Bureau of Medicine and Surgery Falls Church, VA Diana Laco, MSN, RN Disease Management Program Director, 383d Training Squadron (AETC) Fort Sam Houston, TX Saskia Leather, PharmD, BCACP Ambulatory Care Pharmacist, Cardiology and Internal Medicine Clinic, A.T. Augusta Military Medical Center Fort Belvoir, VA Lisa Longo, PharmD, BCPS PBM Clinical Pharmacy Program Manager Pittsburgh, PA Arthur Lyons PhD, MD, COL, USA, MC, FS, FACP, FIDSA Medical Director, Executive Medicine, Office of the Surgeon General Washington, DC Michelle Peacock, MSN, FNP-BC, FAANP Nurse Practitioner, Clinical Nurse Advisor, VA/DOD Coordination Office Washington, DC Lillian Pinault, MS, RDN, LDN, CDCES Diabetes Educator, VISN5 Endocrine Clinical Resource Hub, VA Maryland Healthcare System Baltimore, MD

Kathleen Craig, MSN, RN Lead RN, Virtual Care Integration Program VA Boston Healthcare System, Boston, MA Peter Glassman, MBBS, MSc, FACP Chair, Medical Advisory Panel, Pharmacy Benefit Management Services, Department of Veterans Affairs Los Angeles, CA Elvira Gosmanova, MD, FASN Nephrology Section Chief, Stratton VA Medical Center Albany, NY Cher Hagaman, MSN, GNP-BC, CCNS Heart Failure Nurse Practitioner, Long Beach VA, Long Beach, CA Terri Holt, MSN, RN, CPT, AN Chief Nurse, Army Public Health Nursing, GLWACH, Fort Leonard Wood, MO

Areef Ishani, MD, MS Director of Primary and Specialty Care, Minneapolis VA Minneapolis, MN

Addison Taylor, MD, PhD Staff Physician, Co-director of Vascular Medicine Clinic Michael E. DeBakey VA Medical Center Houston, TX

Mark P. Tschanz, DO, MACM, FACP Fleet Surgeon, Commander U.S. Second Fleet Norfolk, VA Patricia A. Vu, MD, PhD, MPH CPT, MC Director, Department of Public Health Fort Leonard Wood, MO

Celina Yong, MD, MBA, MSc Director of Interventional Cardiology, VA Palo Alto Healthcare Center, Palo Alto, CA

Appendix E: Patient Focus Group Methods and Findings

A. Methods

VA and DOD Leadership recruited seven participants for the focus group with support from the Champions and other Work Group members as needed. The goal of recruitment for this Patient Focus Group was to have a group of engaging, diverse patients receiving VA or DOD healthcare services, who could cogently explain their experience with hypertension. Participants were mixed in terms of receiving care from the VA and DOD, with one receiving care from some civilian providers. Participants’ length of hypertension treatment ranged widely from as recent as two years to as long as 30 years.

The Work Group, with support from Sigma Health Consulting, identified topics on which participants’ input was important to consider in developing the CPG. Sigma Health Consulting developed, and the Work Group approved, an interview guide covering these topics. The focus group facilitator who led the discussion used the guide to elicit the participants’ perspectives about their treatment and overall care. Not all questions included in the Moderator’s Guide for the Hypertension Patient Focus Group were addressed by participants, but because the moderator encouraged conversation between the Patient Focus Group members, most topics were covered.

B. Patient Focus Group Findings

a. Participants stressed the importance of whole-person approaches using individualized treatment plans

• Most participants emphasized that treatments should be individualized because a ‘one- size-fits-all' approach often fails to address high blood pressure. • Many participants mentioned that they wanted to resist ‘lifelong pills’ and instead focus on lifestyle changes like quitting smoking, losing weight, and adjusting their diet.

b. Participants emphasized that continuity of providers, integrated records, care coordination, and communication between VA and DOD systems are essential for effective treatment and engagement.

• Some participants reported that they received care from providers at different facilities, and the communication between providers was lacking, causing discrepancies and the participants feeling as though they had to relay information.
• Overall, participants emphasized the need for stronger communication and coordination amongst all providers (primary care, specialists, pharmacists, etc.)

c. Participants emphasized the importance of accurate screening and early diagnosis of high blood pressure, hyperaldosteronism, and co-occurring conditions.

• Participants noted that early diagnosis and treatment of hypertension and co-occurring conditions would help patients reduce their cardiovascular risk and get their hypertension and the side effects of medications under control sooner.
• Participants also mentioned that accurate screening is valuable and would have helped them receive an effective treatment plan earlier in their hypertension management process.

d. Participants highlighted the value of finding medication(s) that are effective and minimize side effect.

• Participants valued having a medication (or combination) that minimized disruptions to their daily life because of pharmacotherapy side effects or hypertension symptoms.
• The participants also reported having felt relief when they finally found medication(s) that controlled their hypertension.

e. Participants found monitoring hypertension at home to be both beneficial and uncomplicated, utilizing devices and mobile applications to track blood pressure measurements.

• Most participants noted they did not experience difficulty when measuring their blood pressure at home, and sometimes prefer it compared to in a clinic.
• Participants also mentioned that they take advantage of mobile applications to share blood pressure readings taken at home with their healthcare provider

Appendix F. Literature Review Search Terms and Strategy

A. Resources Searched

Sigma’s Information Specialist searched the following databases for relevant information (see Table F-1).

Table F-1. Databases Searched

B. Search Strategies

The search strategies for bibliographic databases employed combinations of free-text keywords as well as controlled vocabulary terms including, but not limited to, the concepts detailed in Tables F-2 and F-3.

Table F-2. EMBASE & MEDLINE SEARCH STRATEGY (EMBASE.COM SYNTAX)

Table F-3. Embase.com Syntax Key

Appendix G. Alt Text Descriptions of Algorithms

The following outlines narratively describe Module A and Module B; an explanation of the purpose of the algorithms and description of the various shapes used within the algorithms can be found in the Algorithm section. The sidebars referenced within these outlines can also be found in the Algorithm section.

A. Module A: Screening and Diagnosis

1. Module A begins with Box 1, in the shape of a rounded rectangle: “Individuals in the health care system with a properly measured blood pressure (Sidebar 1)”. 2. Box 1 connects to Box 2, in the shape of a hexagon, asks the question: “Is the patient currently being treated for hypertension?” a. If the answer is “Yes” to Box 2, then Box 3. b. If the answer is “No” to Box 2, then Box 4. 3. Box 3, in the shape of an oval: “Go to Module B, Box 10”. 4. Box 4, in the shape of a hexagon, asks the question: “Is repeated measurement SBP

≥130mmHg or DBP ≥ 0mmHg? (Sidebars 2 & 4)” a. If the answer is “Yes” to Box 4, then Box 5. b. If the answer is “No” to Box 4, then Box . 5. Box 5, in the shape of a rectangle: “Confirm hypertension diagnosis. (Sidebar 2)

Obtain history, physical and assess for target organ damage and comorbid conditions (Sidebar 3); consider baseline testing as appropriate”. 6. Box 5 connects to Box , in the shape of a hexagon, asks the question: “Is a secondary cause of hypertension suspected?” a. If the answer is “Yes” to Box , then Box 8. b. If the answer is “No” to Box , then Box . 7. Box , in the shape of a rectangle: “Follow up:

• Check blood pressure at routine clinic visits; ▪ Address other CV risk factors and offer lifestyle modifications as appropriate”. 8. Box 8, in the shape of a rectangle: “Evaluate as indicated; consider referral to

specialist”. 9. Box , in the shape of an oval: “Go to Module B, Box 10”.

B. Module B: Treatment

1. Module B begins with Box 10, in the shape of a rounded rectangle: “Patient needs hypertension management and treatment”. 2. Box 10 connects to Box 11, in the shape of a rectangle: “Assess/Reassess patient values and preferences; discuss and implement lifestyle modification utilizing shared- decision making and motivational interviewing (Sidebar 5)”. 3. Box 11 connects to Box 12, in the shape of a hexagon, asks the question: “Patient needs and agrees to pharmacotherapy?” a. If the answer is “Yes” to Box 12, then Box 13. b. If the answer is “No” to Box 12, then Box 14.

4. Box 13, in the shape of a rounded rectangle: “Initiate, continue, or optimize pharmacotherapy (Sidebars 7, 8, 9)”. 5. Box 13 connects to Box 14, in the shape of a rectangle: “Implement one or more of the following (as appropriate) to improve adherence and/or blood pressure control:

• HBPM (home blood pressure monitoring) ▪ Pharmacist-led, nurse-led, or dietitian-led co-interventions (Sidebar 5) ▪ Digital Health Interventions (Sidebar 6)”. 6. Box 15, in the shape of a rectangle: “Follow-up regularly (e.g., monthly) until:
• Blood pressure is at goal (Sidebar 4) ▪ Treatment regimen is optimized (Sidebar 8) Note: Co-occurring conditions and other patient characteristics and preferences may change frequency of follow-up visits.” 7. Box 15 connects to Box 16, in the shape of a hexagon, asks the question: “Is the

patient’s blood pressure at goal?” a. If the answer is “Yes” to Box 18, then Box 17. b. If the answer is “No” to Box 18, then return to Box 13. 8. Box 17, in the shape of a rectangle:

• “Follow up regularly, at least annually or more frequently, based on patient characteristics, co-occurring conditions, etc. ▪ Encourage patient engagement in blood pressure monitoring and healthy lifestyle in between visits.”

Appendix H. Dietary Information

Table H-1: Nutrient Composition of the Dietary Approaches to Stop Hypertension (DASH) *† (139)

Table H-2: Summary of Dietary Recommendations in the Mediterranean Diet*†‡ (33,141)

Appendix I. Drug and Dosage Table (Selected Examples)

a For complete drug information, review the manufacturer’s prescribing information. b DOD Basic Core Formulary (BCF) item. c HCTZ 12.5 mg may be considered as an initial dose with titration recommended to 25 to 50mg daily; refer to Recommendation 12 and associated discussion for further information. d Item not on VA Formulary. e Restricted to treatment of patients with systolic heart failure in VA. Abbreviations: ACEI – angiotensin-converting enzyme inhibitors; ARB – angiotensin II receptor blockers; bid – twice per day; BPH – benign prostatic hyperplasia; CR – controlled release; DHP CCB – dihydropyridine calcium channel blocker; CKD – chronic kidney disease; eGFR – estimated glomerular filtration rate; HCTZ – Hydrochlorothiazide; HF – heart failure; HFrEF – heart failure with reduced ejection fraction; IR – immediate release; K+ – potassium; LV – left ventricle; MI – myocardial infarction; mg – milligrams; qid – four times per day; SR – sustained release; tid – three times per day; XL – extended release

Consult agency formulary for availability. VA: https://www.va.gov/formularyadvisor/, DOD: TRICARE Formulary and Drug Lists | Health.mil

Appendix J. Guidance for Conducting Home Blood Pressure Measurement

The following information has been adapted from the 2019 AHA Measurement of Blood Pressure in Humans.(11)

Patient training provided by healthcare staff or providers:

• Provide information about hypertension diagnosis and treatment, emphasizing:
• Ambulatory blood pressure management is the gold standard for out-of-office blood pressure measurement, but home monitoring is a strong, practical alternative. ▪ Both provide more accurate cardiovascular risk assessment compared to clinic measurements. • Provide information on the proper selection of a device. • Provide instruction on how patients can measure their own blood pressure (if possible, demonstrate the procedure or instruct how to access training video). • Provide instruction that the HBPM device and blood pressure readings (log or electronic recording) should be brought to healthcare visits. • Provide education that individual blood pressure readings may vary greatly (high and low) across the monitoring period.

Preferred devices and cuffs:

• Use an upper-arm cuff oscillometric device that has been validated.
• Use of cuffless devices, often embedded in wearables, should be guided by individual validation studies and calibrated appropriately. • Use a device that is able to automatically store all readings, if possible. • Use a cuff that is appropriately sized for the patient’s arm circumference.

Table J-1. Proper Blood Pressure Cuff Sizes

Cm – centimeters

Best practices for the patient:

• Preparation
• 30 minutes prior:

 Have an empty bladder  No exercise

 No stimulants (e.g., caffeine, alcohol, smoking)

• 5 minutes prior:

 Rest quietly in seated position  No distractions (no TV, phone, or talking)

• Position
• Sit with back supported (e.g., leaning back in chair) ▪ Keep both feet flat on the floor ▪ Legs should not be crossed ▪ Blood pressure cuff should be placed on bare arm (not over clothes) ▪ Blood pressure cuff should be placed directly above the antecubital fossa (bend of the arm) ▪ Center of the bladder of the cuff (commonly marked on the cuff by the manufacturer) should be placed over the arterial pulsation of the patient’s upper arm ▪ Cuff should be pulled taut, with comparable tightness at the top and bottom edges of the cuff, around the upper arm ▪ The arm with the cuff should be supported on a flat surface such as a table
• Number of readings
• Take two readings at least one minute apart in the morning before taking any antihypertensive medications and two readings at least one minute apart in the evening before going to bed; some recommend only recording the second measurement.
• Duration of monitoring
• Preferred monitoring period is ≥ seven days (i.e., 28 or more scheduled readings); a minimum period of three days (i.e., 12 readings) may be sufficient, ideally in the period immediately before the next appointment with the provider. ▪ Monitoring conducted over consecutive days is ideal; however, readings taken on nonconsecutive days may also provide valid data.
• Analyzing readings
• For each monitoring period, the average of all readings should be obtained. Some guidelines and scientific statements recommend excluding the first day of readings. If the first day of readings is excluded, the minimum and preferred periods of HBPM should be four and eight days, respectively.

For a video developed for patients by the VA and DOD with instructions on measuring blood pressure at home, please visit https://www.healthquality.va.gov/guidelines/CD/htn/ and click on the “Home Blood Pressure Monitoring” video.

Appendix K. Guidance for Conducting Office Blood Pressure Measurement

The following information has been adapted from the 2019 AHA Measurement of Blood Pressure in Humans.(142)

• Properly prepare the patient  Have the patient relax, sitting in a chair with feet flat on floor and back supported  The patient should avoid caffeine, exercise, and smoking for at least 30 minutes before measurement  Ensure that the patient has emptied his/her bladder  Neither the patient nor the observer should talk during the measurement  Remove clothing covering the location of cuff placement  Measurements made while the patient is sitting on an examination table do not fulfill these criteria
• Use proper technique for blood pressure measurements  Use an upper-arm cuff blood pressure measurement device that has been validated and ensure that the device is calibrated periodically  Support the patient's arm (e.g., resting on a desk); the patient should not be holding his/her arm because isometric exercise will affect the blood pressure levels  Position the middle of the cuff on the patient's upper arm at the level of the right atrium (midpoint of the sternum)  Use the correct cuff size such that the bladder encircles 75%-100% of the arm Table K-1. Proper Blood Pressure Cuff Sizes

Cm – centimeters

• Take the proper measurements needed for diagnosis and treatment of elevated blood pressure/hypertension  At the first visit, record blood pressure in both arms; use the arm that gives the higher reading for subsequent readings (if consistently 10-15 mmHg higher)  Repeated measurements separated by at least 30 seconds  For subsequent visit- If the BP is within normal limits, <130/90, no second blood pressure reading is necessary

 If the BP is elevated, SBP > 130 and or DBP > 90, conduct a second reading by waiting three to five minutes before repeating.

• Properly document accurate blood pressure readings  Record SBP and DBP  Note the time that the most recent blood pressure medication was taken before measurements
• Provide blood pressure readings to patient  Provide patients with their SBP/DBP readings both verbally and in writing; someone should help the patient interpret the results The steps above should be common to each appropriate standardized office blood pressure measurement technique. The following are additional guidance specific for each technique:
• For fully automated office oscillometric manometer readings:  Preprogram the manometer to wait five minutes before inflation begins and to take and average two to three readings at least 30 seconds apart; the most common intervals are 30 seconds, one minute, and two minutes.  Position the patient and place the properly sized cuff on the upper arm before initiating the wait time and blood pressure readings.  Turn the manometer on and set controls to inflate to the proper level (above sensed SBP) automatically and measure and average multiple readings; press the button to initiate wait period and automated readings (fully automated).  Patient should remain quiet and not use electronic devices (e.g., phones) during the rest period and readings; the person measuring the blood pressure may remain in the room (attended) or leave the patient alone in the room (unattended), but no one should interact or speak with the patient during the rest period and readings.  After the rest and measurements are completed, record the average blood pressure reading displayed; the manometer should display the average of the two to three readings (as preset).
• For standard technique with automated oscillometric device:  Use an upper-arm cuff oscillometric device that has been validated.  Position the patient and place the proper sized cuff on the upper arm before initiating the wait time and blood pressure readings.  Turn the manometer on and set controls to take/inflate to proper level (above sensed SBP) automatically.  Patient should remain quiet and not use electronic devices (e.g., phones), and no one should speak with the patient during the rest period and readings.  Push the button to initiate the first inflation/reading; record SBP and DBP reading.

 If the BP is elevated, SBP > 130 and or DBP > 90, conduct a second reading by waiting three to five minutes before repeating. • For standard auscultatory technique with a manual manometer:  Use an upper-arm cuff manual device that has been validated and recently calibrated; this includes a mercury manometer, an aneroid manometer, or an electronic manual non-oscillometric manometer for auscultatory determinations.  Position the patient and place the properly sized cuff on the upper arm before initiating the wait time and blood pressure readings.  Patient should remain quiet and not use electronic devices (e.g., phones), and no one should speak with the patient during the rest period and readings.  Use a palpated estimate of radial pulse obliteration pressure (disappearance or resumption of pulse when cuff is inflated/deflated) to estimate SBP; inflate the cuff 20- 30 mmHg above this level to perform the auscultatory determination of the blood pressure level.  Use either the stethoscope diaphragm or bell for auscultatory readings.  Inflate the cuff and use auscultation to determine SBP and DBP; determine SBP and DBP as the onset of the first of at least two consecutive Korotkoff sounds (beats) and the last audible Korotkoff sound, respectively.  Record the SBP and DBP readings.  If the BP is elevated, SBP > 130 and or DBP > 90, conduct a second reading by waiting three to five minutes before repeating and record SBP and DBP readings for each reading.

Appendix L. Abbreviation List

References

1. Evidence Based Practice Work Group Charter (2017). 2. Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. Apr 2011;64(4):395-400. doi:10.1016/j.jclinepi.2010.09.012 3. Whelton SP, McEvoy JW, Shaw L, et al. Association of Normal Systolic Blood Pressure Level With Cardiovascular Disease in the Absence of Risk Factors. JAMA Cardiol. Sep 1 2020;5(9):1011-1018. doi:10.1001/jamacardio.2020.1731 4. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. Dec 14 2002;360(9349):1903-13. doi:10.1016/s0140-6736(02)11911-8 5. Dalen JE, Alpert JS, Goldberg RJ, Weinstein RS. The epidemic of the 20(th) century: coronary heart disease. Am J Med. Sep 2014;127(9):807-12. doi:10.1016/j.amjmed.2014.04.015 6. Hamrahian SM, Maarouf OH, Fülöp T. A Critical Review of Medication Adherence in Hypertension: Barriers and Facilitators Clinicians Should Consider. Patient Prefer Adherence. 2022;16:2749-2757. doi:10.2147/ppa.S368784 7. Centers for Disease Control. Multiple cause of death data on CDC WONDER. https://wonder.cdc.gov/mcd.html 8. Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation. Feb 20 2024;149(8):e347-e913. doi:10.1161/cir.0000000000001209 9. Fryar CD, Kit B, Carroll MD, Afful J. Hypertension Prevalence, Awareness, Treatment, and Control Among Adults Age 18 and Older: United States, August 2021-August 2023. NCHS Data Brief. Oct 2024;(511) 10. Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension. Mar 1995;25(3):305-13. doi:10.1161/01.hyp.25.3.305 11. Lloyd-Jones DM, Bansal, N., Collins, K. J., Johnson, H. M., Khan, S. S., , Altieri, M. M., Williamson, J. D., Smith, S. C., Ferdinand, K. C., Talbot, A. W., Cohen, J. B., Schott, S. L., Carter, J., Ogunniyi, M. O., Vongpatanasin, W., Jones, D. W., Bress, A. P., Melnyk, B. M., … Davis, L. L. AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2025;152(11):e114-e218. 12. Lee JH, Kim S-H, Kang S-H, et al. Blood Pressure Control and Cardiovascular Outcomes: Real-world Implications of the 2017 ACC/AHA Hypertension Guideline. Scientific Reports. 2018/09/03 2018;8(1):13155. doi:10.1038/s41598-018-31549-5 13. Jaeger BC, Chen L, Foti K, et al. Hypertension Statistics for US Adults: An Open-Source Web Application for Analysis and Visualization of National Health and Nutrition Examination Survey Data. Hypertension. 2023/06/01 2023;80(6):1311-1320. doi:10.1161/HYPERTENSIONAHA.123.20900 14. Muntner P, Carey RM, Gidding S, et al. Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline. Circulation. Jan 9 2018;137(2):109-118. doi:10.1161/circulationaha.117.032582 15. Lind KE, Wong MS, Frochen SE, Yuan AH, Washington DL. Variation in Hypertension Control by Race and Ethnicity, and Geography in US Veterans. J Am Heart Assoc. Jan 21 2025;14(2):e035682. doi:10.1161/jaha.123.035682

16. Sarah O. Meadows CCE, Rebecca L. Collins, Robin L. Beckman, Joshua Breslau, Erika Litvin Bloom, Michael S. Dunbar, Marylou Gilbert, David Grant, Jennifer Hawes-Dawson, et al. 2018 Department of Defense Health Related Behaviors Survey (HRBS). https://www.rand.org/pubs/research_reports/RR4222.html 17. Granado NS, Smith TC, Swanson GM, et al. Newly reported hypertension after military combat deployment in a large population-based study. Hypertension. Nov 2009;54(5):966- 73. doi:10.1161/hypertensionaha.109.132555 18. Shrestha A, Ho TE, Vie LL, et al. Comparison of Cardiovascular Health Between US Army and Civilians. J Am Heart Assoc. Jun 18 2019;8(12):e009056. doi:10.1161/jaha.118.009056 19. U.S. Department of Veterans Affairs VHA, Office of Health Equity,. National Veteran Health Equity Report 2021. https://www.va.gov/HEALTHEQUITY/docs/NVHER_2021_Report_508_Conformant.pdf 20. Centers for Disease Control and Prevention. Hypertension cascade: hypertension prevalence, treatment and control estimates among US adults aged 18 years and older applying the criteria from the American College of Cardiology and American Heart Association's 2017 Hypertension Guideline—NHANES 2017–March 2020. . https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html 21. Donna L. Washington M, MPH, OHE-QUERI PEC Director, VA Greater Los Angeles Healthcare System, Lauren Korshak, , DHealth(c) M, RCEP, Office of Health Equity, Kelly Burkitt, PhD, Center for Health Equity Research and Promotion (CHERP), , Melissa M. Farmer P, VA Greater Los Angeles Healthcare System, and Bevanne Bean-Mayberry, MD, MHS, VA Greater Los Angeles , System H. RATES OF HYPERTENSION BY RACE OR ETHNICITY IN VETERANS RECEIVING CARE AT VA https://www.va.gov/HEALTHEQUITY/docs/Rates_of_Hypertension_by_Race_or_Ethnicity .pdf 22. Rhee J, Beltran T, Choi YS. Elevated Blood Pressure Among Military Emergency Department Patients. Mil Med. Sep 1 2025;190(Supplement_2):704-709. doi:10.1093/milmed/usaf314 23. Moore BA, Tison LM, Palacios JG, Peterson AL, Mysliwiec V. Incidence of insomnia and obstructive sleep apnea in active duty United States military service members. Sleep. Jul 9 2021;44(7)doi:10.1093/sleep/zsab024 24. Knapik JJ, Trone DW, Steelman RA, Farina EK, Lieberman HR. Prevalence of and Factors Associated with Dietary Supplement Use in a Stratified, Random Sample of US Military Personnel: The US Military Dietary Supplement Use Study. J Nutr. Nov 2 2021;151(11):3495-3506. doi:10.1093/jn/nxab239 25. Hruby A, Lieberman HR, Smith TJ. Self-reported health behaviors, including sleep, correlate with doctor-informed medical conditions: data from the 2011 Health Related Behaviors Survey of U.S. Active Duty Military Personnel. BMC Public Health. Jul 11 2018;18(1):853. doi:10.1186/s12889-018-5781-2 26. Howard JT, Sosnov JA, Janak JC, et al. Associations of Initial Injury Severity and Posttraumatic Stress Disorder Diagnoses With Long-Term Hypertension Risk After Combat Injury. Hypertension. May 2018;71(5):824-832. doi:10.1161/hypertensionaha.117.10496 27. Howard JT, Stewart IJ, Kolaja CA, et al. Hypertension in military veterans is associated with combat exposure and combat injury. J Hypertens. Jul 2020;38(7):1293-1301. doi:10.1097/hjh.0000000000002364 28. Johnson MC, Banaag AL, Condie KJ, Servies TE, Pérez Koehlmoos TL. New ACC/AHA Blood Pressure Guidelines and the Operational Readiness of Naval Aviators and Aircrew. Aerosp Med Hum Perform. Apr 1 2019;90(4):409-414. doi:10.3357/amhp.5229.2019

29. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. Jun 2018;71(6):e13-e115. doi:10.1161/hyp.0000000000000065 30. Guideline for guidelines. Veterans Health Administration, Office of Quality & Performance, Evidence Review Subgroup (2019). 31. Ransohoff DF, Pignone M, Sox HC. How to decide whether a clinical practice guideline is trustworthy. Jama. Jan 9 2013;309(2):139-40. doi:10.1001/jama.2012.156703 32. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation's direction and strength. Journal of Clinical Epidemiology. 07/2013 2013;66(7):726-735. doi:10.1016/j.jclinepi.2013.02.003 33. 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):719-25. doi:10.1016/j.jclinepi.2012.03.013 34. Schünemann HJ, Fretheim A, Oxman AD. Improving the use of research evidence in guideline development: 10. Integrating values and consumer involvement. Health Res Policy Syst. Dec 5 2006;4:22. doi:10.1186/1478-4505-4-22 35. Newberry SJ, Ahmadzai N, Motala A, et al. AHRQ Methods for Effective Health Care. Surveillance and identification of signals for updating systematic reviews: Implementation and early experience. Agency for Healthcare Research and Quality (US); 2013. 36. Standards for Guideline Development (2018). 37. Martínez García L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated recommendations: an assessment of NICE clinical guidelines. Implementation Science. 12/2014 2014;9(1):72. doi:10.1186/1748-5908-9-72 38. National Institute for Health and Care Excellence. The Guidelines Manual. 2012. https://www.nice.org.uk/process/pmg6/chapter/introduction 39. Financial Relationships Between VHA Health Care Professionals and Industry (2014). 40. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient‐centered care and adherence: Definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners. 12/2008 2008;20(12):600-607. doi:10.1111/j.1745-7599.2008.00360.x 41. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. Sep 2000;49(9):796-804. 42. Consortium NL. Shared Decision Making 2013; 43. Institute of Medicine Committee on Quality of Health Care in A. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US) Copyright 2001 by the National Academy of Sciences. All rights reserved.; 2001.

44. Society for Medical Decision Making Committee on Standardization of Clinical Algorithms. Proposal for Clinical Algorithm Standards: Society for Medical Decision Making Committee on Standardization of Clinical Algorithms*. Medical Decision Making. 06/1992 1992;12(2):149-154. doi:10.1177/0272989X9201200208 45. Appel LJ, Moore TJ, Obarzanek E, et al. A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. New England Journal of Medicine. 1997;336(16):1117-1124. doi:doi:10.1056/NEJM199704173361601 46. Juraschek SP, Miller ER, Weaver CM, Appel LJ. Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure. Journal of the American College of Cardiology. 2017/12/12/ 2017;70(23):2841-2848. doi:https://doi.org/10.1016/j.jacc.2017.10.011

47. Krishnamoorthy Y, Nagarajan R, Murali S. Effectiveness of multiple combined lifestyle interventions in reducing blood pressure among patients with prehypertension and hypertension: a network meta-analysis. Article. Journal of public health (Oxford, England). 2023;45(2):e319-e331. doi:10.1093/pubmed/fdac027 48. Pescatello LS, Wu Y, Gao S, Livingston J, Sheppard BB, Chen MH. Do the combined blood pressure effects of exercise and antihypertensive medications add up to the sum of their parts? A systematic meta-review. BMJ Open Sport Exerc Med. 2021;7(1):e000895. doi:10.1136/bmjsem-2020-000895 49. Yang S, Zhou Z, Miao H, Zhang Y. Effect of weight loss on blood pressure changes in overweight patients: A systematic review and meta-analysis. The Journal of Clinical Hypertension. 2023/05/01 2023;25(5):404-415. doi:https://doi.org/10.1111/jch.14661 50. Riegel GR, Ribeiro PAB, Rodrigues MP, Zuchinali P, Moreira LB. Efficacy of nutritional recommendations given by registered dietitians compared to other healthcare providers in reducing arterial blood pressure: Systematic review and meta-analysis. Clin Nutr. Apr 2018;37(2):522-531. doi:10.1016/j.clnu.2016.12.019 51. Mills KT, O'Connell SS, Pan M, Obst KM, He H, He J. Role of Health Care Professionals in the Success of Blood Pressure Control Interventions in Patients With Hypertension: A Meta-Analysis. Circ Cardiovasc Qual Outcomes. Aug 2024;17(8):e010396. doi:10.1161/circoutcomes.123.010396 52. Kaihara T, Intan-Goey V, Scherrenberg M, et al. Automatic transmission of home blood pressure data can be effective in managing hypertension: a systematic review and meta- analysis. Eur Heart J Digit Health. Dec 2022;3(4):638-653. doi:10.1093/ehjdh/ztac049 53. Motta-Yanac E, Riley V, Ellis NJ, Mankoo A, Gidlow CJ. The digital prescription: A systematic review and meta-analysis of smartphone apps for blood pressure control. International Journal of Medical Informatics. 2025/03/01/ 2025;195:105755. doi:https://doi.org/10.1016/j.ijmedinf.2024.105755 54. Wang N, Salam A, Pant R, et al. Blood pressure-lowering efficacy of antihypertensive drugs and their combinations: a systematic review and meta-analysis of randomised, double-blind, placebo-controlled trials. The Lancet. 2025;406(10506):915-925. doi:10.1016/S0140-6736(25)00991-2 55. Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. Dec 4 2008;359(23):2417-28. doi:10.1056/NEJMoa0806182 56. Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ. Combination Therapy Versus Monotherapy in Reducing Blood Pressure: Meta-analysis on 11,000 Participants from 42 Trials. The American Journal of Medicine. 2009/03/01/ 2009;122(3):290-300. doi:https://doi.org/10.1016/j.amjmed.2008.09.038 57. Pappaccogli M, Di Monaco S, Perlo E, et al. Comparison of Automated Office Blood Pressure With Office and Out-Off-Office Measurement Techniques. Hypertension. Feb 2019;73(2):481-490. doi:10.1161/hypertensionaha.118.12079 58. Roerecke M, Kaczorowski J, Myers MG. Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension: A Systematic Review and Meta-analysis. JAMA Internal Medicine. 2019;179(3):351-362. doi:10.1001/jamainternmed.2018.6551 59. Sánchez Bacaicoa M, Rico S, Gullón A, et al. Automated Office Blood Pressure Measurements in Waiting Room or Isolated Room for Diagnosis and Phenotyping of Hypertension. Article. Journal of the American Heart Association. 2025;14(20):e038011. doi:10.1161/JAHA.124.038011 60. Karnjanapiboonwong A, Anothaisintawee T, Chaikledkaew U, Dejthevaporn C, Attia J, Thakkinstian A. Diagnostic performance of clinic and home blood pressure measurements compared with ambulatory blood pressure: a systematic review and meta-analysis. Article. BMC Cardiovascular Disorders. 2020;20(1)doi:10.1186/s12872-020-01736-2 61. Mizuno H, Choi E, Kario K, et al. Diagnostic Accuracy of Office Blood Pressure Measurement and Home Blood Pressure Monitoring for Hypertension Screening Among Adults: Results From the IDH Study. Article. Journal of the American Heart Association. 2023;12(24)doi:10.1161/JAHA.123.030150 62. Walsh S, Choi E, Fang C, et al. The Diagnostic Accuracy of Using Borderline High Office Blood Pressure Thresholds to Diagnose Masked Hypertension According to the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. Article. American Journal of Hypertension. 2025;38(5):288-294. doi:10.1093/ajh/hpaf017 63. Antza C, Anyfanti P, Kotoulas SC, Kotsis V. Diagnostic accuracy of blood pressure measurement methods for hypertension screening in obesity: does one fit all? Article. Journal of hypertension. 2025;43(12):1991-1998. doi:10.1097/HJH.0000000000004142 64. Guirguis-Blake JM, Evans CV, Webber EM, Coppola EL, Perdue LA, Weyrich MS. Screening for Hypertension in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. Review. JAMA - Journal of the American Medical Association. 2021;325(16):1657-1669. doi:10.1001/jama.2020.21669 65. Kim JS, Rhee MY, Kim CH, et al. Algorithm for diagnosing hypertension using out-of-office blood pressure measurements. Article. Journal of Clinical Hypertension. 2021;23(11):1965-1974. doi:10.1111/jch.14382 66. Constanti M, Boffa R, Floyd CN, Wierzbicki AS, McManus RJ, Glover M. Options for the diagnosis of high blood pressure in primary care: a systematic review and economic model. Article. Journal of Human Hypertension. 2021;35(5):455-461. doi:10.1038/s41371- 020-0357-x 67. Sarkar A, Nwokocha C, Nash SG, Grigoryan L. Empowering Low-Income Patients with Home Blood Pressure Monitors to Improve Hypertension Control. J Am Board Fam Med. Mar-Apr 2024;37(2):187-195. doi:10.3122/jabfm.2023.230357R1 68. Hassanein M, Kumwenda MJ, Hemida K, et al. Structured hypertension education program for people with type 2 diabetes, the SHED study. Diabetes Res Clin Pract. May 2021;175:108773. doi:10.1016/j.diabres.2021.108773 69. Cuffee YL, Sciamanna C, Gerin W, et al. The Effectiveness of Home Blood Pressure on 24-Hour Blood Pressure Control: A Randomized Controlled Trial. Am J Hypertens. Jan 15 2019;32(2):186-192. doi:10.1093/ajh/hpy160 70. Muhammad J, Jamial MM, Ishak A. Home Blood Pressure Monitoring Has Similar Effects on Office Blood Pressure and Medication Compliance as Usual Care. Korean J Fam Med. Sep 2019;40(5):335-343. doi:10.4082/kjfm.18.0026 71. Kim CJ, Kim M, Lee GY, Park E, Schlenk EA. Effectiveness of nurse-led interventions on medication adherence in adults taking medication for metabolic syndrome: A systematic review and meta-analysis. J Clin Nurs. Aug 2023;32(15-16):5328-5356. doi:10.1111/jocn.16589 72. Svarstad BL, Brown RL, Shireman TI. A successful intervention to improve medication adherence in Black patients with hypertension: Mediation analysis of 28-site TEAM trial. J Am Pharm Assoc (2003). May-Jun 2022;62(3):800-808.e3. doi:10.1016/j.japh.2022.01.002 73. Torres-Robles A, Benrimoj SI, Gastelurrutia MA, et al. Effectiveness of a medication adherence management intervention in a community pharmacy setting: a cluster randomised controlled trial. BMJ Qual Saf. Feb 2022;31(2):105-115. doi:10.1136/bmjqs- 2020-011671 74. Blecker S, Mann DM, Martinez TR, et al. Medication Adherence in Hypertension: A Cluster Randomized Clinical Trial. JAMA Cardiology. 2025;10(9):914-921. doi:10.1001/jamacardio.2025.2155

75. Halvorsen LV, Søraas CL, Larstorp ACK, et al. Effect of Therapeutic Drug Monitoring on Adherence and Blood Pressure: A Multicenter Randomized Clinical Trial. Am J Hypertens. Sep 16 2024;37(10):826-836. doi:10.1093/ajh/hpae059 76. Mikulski BS, Bellei EA, Biduski D, De Marchi ACB. Mobile Health Applications and Medication Adherence of Patients With Hypertension: A Systematic Review and Meta- Analysis. American Journal of Preventive Medicine. 2022/04/01/ 2022;62(4):626-634. doi:https://doi.org/10.1016/j.amepre.2021.11.003 77. Kassavou A, Wang M, Mirzaei V, Shpendi S, Hasan R. The Association Between Smartphone App-Based Self-monitoring of Hypertension-Related Behaviors and Reductions in High Blood Pressure: Systematic Review and Meta-analysis. JMIR Mhealth Uhealth. Jul 12 2022;10(7):e34767. doi:10.2196/34767 78. Mehas N, Hudmon KS, Jaynes H, Klink S, Downey L, Zillich AJ. Impact of Electronic Medication Reminder Caps on Patient Adherence and Blood Pressure. Journal of Pharmacy Technology. 2021/10/01 2021;37(5):234-243. doi:10.1177/87551225211018708 79. Meng F, Jiang Y, Yu P, et al. Effect of health coaching on blood pressure control and behavioral modification among patients with hypertension: A systematic review and meta- analysis of randomized controlled trials. International Journal of Nursing Studies. 2023/02/01/ 2023;138:104406. doi:https://doi.org/10.1016/j.ijnurstu.2022.104406 80. Haze T, Katsurada K, Sakata S, et al. Effect of intensive versus standard blood pressure control on cardiovascular outcomes in adult patients with hypertension: a systematic review and meta-analysis. Hypertens Res. Jun 2025;48(6):1846-1858. doi:10.1038/s41440-025-02131-0 81. Rizwanullah U, Vineesh A, Hyderi FA, et al. Impact of Intensive Blood Pressure Control Versus Standard Control on Cardiovascular Outcomes: A Systematic Review and Meta- Analysis of Randomized Controlled Trials. Cureus. Jul 2025;17(7):e87456. doi:10.7759/cureus.87456 82. Matsumoto C, Nagai M, Shinohara K, Morikawa N, Kai H, Arima H. Systolic blood pressure lower than 130 mmHg in heart failure with preserved ejection fraction: a systematic review and meta-analysis of clinical outcomes. Hypertens Res. Aug 2025;48(8):2138-2151. doi:10.1038/s41440-025-02240-w 83. ACCORD Study Group. Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus. New England Journal of Medicine. 362(17):1575-1585. doi:10.1056/NEJMoa1001286 84. Liu J, Li Y, Ge J, et al. Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial. Lancet. Jul 20 2024;404(10449):245-255. doi:10.1016/s0140-6736(24)01028-6 85. STEP Study Group. Five-Year Findings of the Hypertension Detection and Follow-up Program: I. Reduction in Mortality of Persons With High Blood Pressure, Including Mild Hypertension. JAMA. 1979;242(23):2562-2571. doi:10.1001/jama.1979.03300230018021 86. Fallahtafti P, Semirani-Nezhad D, Maleki S, et al. Intensive versus Less-Intensive Blood Pressure Control in Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Clinical Trials. Am J Nephrol. Aug 6 2025:1-15. doi:10.1159/000547812 87. U.S. Department of Veteran Affairs DoD. Diagnosis and Management of Hypertension (HTN) in Primary Care Clinical Practice Guideline. https://www.healthquality.va.gov/HEALTHQUALITY/guidelines/CD/htn/VADODHypertensi onCPG508Corrected792020.pdf 88. Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev. Jul 20 2018;7(7):Cd010315. doi:10.1002/14651858.CD010315.pub3

89. MRC Working Party. MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party. Br Med J (Clin Res Ed). Jul 13 1985;291(6488):97-104. doi:10.1136/bmj.291.6488.97 90. Hypertension Detection and Follow-up Program Cooperative Group. The Effect of Treatment on Mortality in Mild Hypertension. New England Journal of Medicine. 1982;307(16):976-980. doi:doi:10.1056/NEJM198210143071603 91. Effects Morbidity of Treatment on in Hypertension: II. Results in Patients With Diastolic Blood Pressure Averaging 90 Through 114 mm Hg. JAMA. 1970;213(7):1143-1152. doi:10.1001/jama.1970.03170330025003 92. Effects of Treatment on Morbidity in Hypertension: Results in Patients With Diastolic Blood Pressures Averaging 115 Through 129 mm Hg. JAMA. 1967;202(11):1028-1034. doi:10.1001/jama.1967.03130240070013 93. Reboldi G, Angeli F, Gentile G, Verdecchia P. Benefits of more intensive versus less intensive blood pressure control. Updated trial sequential analysis. Eur J Intern Med. Jul 2022;101:49-55. doi:10.1016/j.ejim.2022.03.032 94. Arguedas JA, Leiva V, Wright JM. Blood pressure targets in adults with hypertension. Cochrane Database Syst Rev. Dec 17 2020;12(12):Cd004349. doi:10.1002/14651858.CD004349.pub3 95. Baffour-Awuah B, Dieberg G, Pearson MJ, Smart NA. Blood pressure control in older adults with hypertension: A systematic review with meta-analysis and meta-regression. Int J Cardiol Hypertens. Sep 2020;6:100040. doi:10.1016/j.ijchy.2020.100040 96. Bi Y, Li M, Liu Y, et al. Intensive Blood-Pressure Control in Patients with Type 2 Diabetes. New England Journal of Medicine. 2025;392(12):1155-1167. doi:doi:10.1056/NEJMoa2412006 97. SPRINT Study Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. New England Journal of Medicine. 2015;373(22):2103-2116. doi:doi:10.1056/NEJMoa1511939 98. Siopis G, Moschonis G, Eweka E, et al. Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with hypertension: a systematic review and meta- analysis of randomised controlled trials. The Lancet Digital Health. 2023;5(3):e144-e159. doi:10.1016/S2589-7500(23)00002-X 99. Kelly FA, Moraes FCA, Lôbo AOM, et al. The effect of telehealth on clinical outcomes in patients with hypertension and diabetes: A meta-analysis of 106,261 patients. J Telemed Telecare. Dec 2025;31(10):1382-1400. doi:10.1177/1357633x241298169 100. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure-lowering on outcome incidence in hypertension: 5. Head-to-head comparisons of various classes of antihypertensive drugs - overview and meta-analyses. J Hypertens. Jul 2015;33(7):1321- 41. doi:10.1097/hjh.0000000000000614 101. Reinhart M, Puil L, Salzwedel DM, Wright JM. First-line diuretics versus other classes of antihypertensive drugs for hypertension. Cochrane Database Syst Rev. Jul 13 2023;7(7):Cd008161. doi:10.1002/14651858.CD008161.pub3 102. Zhu J, Chen N, Zhou M, et al. Calcium channel blockers versus other classes of drugs for hypertension. Cochrane Database Syst Rev. Oct 17 2021;10(10):Cd003654. doi:10.1002/14651858.CD003654.pub5 103. Yu D, Li JX, Cheng Y, et al. Comparative efficacy of different antihypertensive drug classes for stroke prevention: A network meta-analysis of randomized controlled trials. PLoS One. 2025;20(2):e0313309. doi:10.1371/journal.pone.0313309 104. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 14 - effects of different classes of antihypertensive drugs in older and younger patients: overview and meta-analysis. J Hypertens. Aug 2018;36(8):1637-1647. doi:10.1097/hjh.0000000000001777

105. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Jama. Dec 18 2002;288(23):2981-97. doi:10.1001/jama.288.23.2981 106. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. May 1 2008;358(18):1887-98. doi:10.1056/NEJMoa0801369 107. Ishani A, Cushman William C, Leatherman Sarah M, et al. Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events. New England Journal of Medicine. 2022/12/28 2022;387(26):2401-2410. doi:10.1056/NEJMoa2212270 108. Musini VM, Tejani AM, Bassett K, Puil L, Thompson W, Wright JM. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database Syst Rev. Oct 9 2025;10(10):Cd000028. doi:10.1002/14651858.CD000028.pub4 109. Williams B, MacDonald TM, Morant S, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. Nov 21 2015;386(10008):2059-2068. doi:10.1016/s0140-6736(15)00257-3 110. Tian Z, Vollmer Barbosa C, Lang H, Bauersachs J, Melk A, Schmidt BMW. Efficacy of pharmacological and interventional treatment for resistant hypertension: a network meta- analysis. Cardiovasc Res. Feb 27 2024;120(1):108-119. doi:10.1093/cvr/cvad165 111. Lee CJ, Ihm SH, Shin DH, et al. Spironolactone vs Amiloride for Resistant Hypertension: A Randomized Clinical Trial. Jama. Jun 17 2025;333(23):2073-2082. doi:10.1001/jama.2025.5129 112. Krieger EM, Drager LF, Giorgi DMA, et al. Spironolactone Versus Clonidine as a Fourth- Drug Therapy for Resistant Hypertension: The ReHOT Randomized Study (Resistant Hypertension Optimal Treatment). Hypertension. Apr 2018;71(4):681-690. doi:10.1161/hypertensionaha.117.10662 113. Flack JM, Azizi M, Brown JM, et al. Efficacy and Safety of Baxdrostat in Uncontrolled and Resistant Hypertension. N Engl J Med. Oct 9 2025;393(14):1363-1374. doi:10.1056/NEJMoa2507109 114. Fouassier D, Blanchard A, Fayol A, et al. Sequential nephron blockade with combined diuretics improves diastolic function in patients with resistant hypertension. ESC Heart Fail. Oct 2020;7(5):2561-2571. doi:10.1002/ehf2.12832 115. Laffin LJ, Kopjar B, Melgaard C, et al. Lorundrostat Efficacy and Safety in Patients with Uncontrolled Hypertension. New England Journal of Medicine. 2025;392(18):1813-1823. doi:doi:10.1056/NEJMoa2501440 116. Nolde JM, Atkins E, Marschner S, et al. Effect of Initial Treatment With a Single Pill Containing Quadruple Combination of Quarter Doses of Blood Pressure Medicines Versus Standard Dose Monotherapy in Patients With Hypertension on Ambulatory Blood Pressure Indices: Results From the QUARTET Study. Circulation. 2023/07/25 2023;148(4):375-377. doi:10.1161/CIRCULATIONAHA.123.064964 117. MacDonald TM, Williams B, Webb DJ, et al. Combination Therapy Is Superior to Sequential Monotherapy for the Initial Treatment of Hypertension: A Double‐Blind Randomized Controlled Trial. Journal of the American Heart Association. 6(11):e006986. doi:10.1161/JAHA.117.006986 118. Wang N, Rueter P, Atkins E, et al. Efficacy and Safety of Low-Dose Triple and Quadruple Combination Pills vs Monotherapy, Usual Care, or Placebo for the Initial Management of Hypertension: A Systematic Review and Meta-analysis. JAMA Cardiol. Jun 1 2023;8(6):606-611. doi:10.1001/jamacardio.2023.0720 119. Basile C, Merolla A, Mancusi C, et al. Effect of incretin-based therapies on blood pressure: a systematic review and meta-analysis. European Journal of Preventive Cardiology. 2025;doi:10.1093/eurjpc/zwaf560

120. Siebenhofer A, Winterholer S, Jeitler K, et al. Long-term effects of weight-reducing drugs in people with hypertension. Cochrane Database Syst Rev. Jan 17 2021;1(1):Cd007654. doi:10.1002/14651858.CD007654.pub5 121. Wang L, Lin M, Yu J, et al. The Impact of Bariatric Surgery Versus Non-Surgical Treatment on Blood Pressure: Systematic Review and Meta-Analysis. Obes Surg. Nov 2021;31(11):4970-4984. doi:10.1007/s11695-021-05671-9 122. Shi Q, Wang Y, Hao Q, et al. Pharmacotherapy for adults with overweight and obesity: a systematic review and network meta-analysis of randomised controlled trials. The Lancet. 2024/04/06/ 2024;403(10434):e21-e31. doi:https://doi.org/10.1016/S0140-6736(24)00351- 9 123. Gadde KM, Allison DB, Ryan DH, et al. Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial. The Lancet. 2011;377(9774):1341-1352. doi:10.1016/S0140-6736(11)60205-5 124. Hesdorffer DC, Kanner AM. The FDA alert on suicidality and antiepileptic drugs: Fire or false alarm? Epilepsia. 2009/05/01 2009;50(5):978-986. doi:https://doi.org/10.1111/j.1528- 1167.2009.02012.x 125. Unda Villafuerte F, Llobera Cànaves J, Estela Mantolan A, et al. Effectiveness of medication self-management, self-monitoring and a lifestyle intervention on hypertension in poorly controlled patients: The MEDICHY randomized trial. Clinical Trial. Frontiers in Cardiovascular Medicine. 2024-May-21 2024;Volume 11 - 2024doi:10.3389/fcvm.2024.1355037 126. Blumenthal JA, Hinderliter AL, Smith PJ, et al. Effects of Lifestyle Modification on Patients With Resistant Hypertension: Results of the TRIUMPH Randomized Clinical Trial. Circulation. 2021/10/12 2021;144(15):1212-1226. doi:10.1161/CIRCULATIONAHA.121.055329 127. Hinderliter AL, Smith P, Sherwood A, Blumenthal J. Lifestyle Interventions Reduce the Need for Guideline-Directed Antihypertensive Medication. American Journal of Hypertension. 2021;34(10):1100-1107. doi:10.1093/ajh/hpab090 128. Sayón-Orea C, Razquin C, Bulló M, et al. Effect of a Nutritional and Behavioral Intervention on Energy-Reduced Mediterranean Diet Adherence among Patients with Metabolic Syndrome: Interim Analysis of the PREDIMED-Plus Randomized Clinical Trial. Article. JAMA - Journal of the American Medical Association. 2019;322(15):1486-1499. doi:10.1001/jama.2019.14630 129. Herrod PJJ, Doleman B, Blackwell JEM, et al. Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta- analysis. J Am Soc Hypertens. Apr 2018;12(4):248-267. doi:10.1016/j.jash.2018.01.008 130. Palicherla A, Abusnina W, Kapaganti S, Dahal K. SODIUM RESTRICTION IN HEART FAILURE: A META-ANALYSIS OF RANDOMIZED TRIALS. JACC. 2023/03/07 2023;81(8_Supplement):334-334. doi:10.1016/S0735-1097(23)00778-7 131. uader ZS, Zhao L, Gillespie C, et al. Sodium Intake Among Persons Aged ≥2 Years - United States, 2013-2014. MMWR Morb Mortal Wkly Rep. Mar 31 2017;66(12):324-328. doi:10.15585/mmwr.mm6612a3 132. Piaggio D, Bracale U, Pecchia L, Di Taranto MD, Sodo M, Bracale UM. Endovascular Treatment versus Medical Therapy for Hypertensive Patients with Renal Artery Stenosis: An Updated Systematic Review. Annals of Vascular Surgery. 2019;61:445-454. doi:10.1016/j.avsg.2019.04.050 133. Cooper Christopher J, Murphy Timothy P, Cutlip Donald E, et al. Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis. New England Journal of Medicine. 370(1):13-22. doi:10.1056/NEJMoa1310753

134. Revascularization versus Medical Therapy for Renal-Artery Stenosis. New England Journal of Medicine. 361(20):1953-1962. doi:10.1056/NEJMoa0905368 135. Bax L, Woittiez AJ, Kouwenberg HJ, et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med. Jun 16 2009;150(12):840-8, w150-1. doi:10.7326/0003-4819-150-12-200906160-00119 136. Marcantoni C, Zanoli L, Rastelli S, et al. Effect of Renal Artery Stenting on Left Ventricular Mass: A Randomized Clinical Trial. American Journal of Kidney Diseases. 2012;60(1):39- 46. doi:10.1053/j.ajkd.2012.01.022 137. Gonçalves OR, Kelly FA, Maia JG, et al. Assessing the efficacy of renal denervation in patients with resistant arterial hypertension. Herz. 2025/02/01 2025;50(1):34-41. doi:10.1007/s00059-024-05268-9 138. Samson D, Schoelles KM. AHRQ Methods for Effective Health Care Developing the Topic and Structuring Systematic Reviews of Medical Tests: Utility of PICOTS, Analytic Frameworks, Decision Trees, and Other Frameworks. In: Chang SM, Matchar DB, Smetana GW, Umscheid CA, eds. Methods Guide for Medical Test Reviews. Agency for Healthcare Research and Quality (US); 2012.

139. U.S. Dept. of Health and Human Services NIoH, National Heart, Lung, and Blood Institute. Your guide to lowering your blood pressure with DASH: DASH eating plan: Lower your blood pressure. . https://www.nhlbi.nih.gov/files/docs/public/heart/new_dash.pdf 140. Vollmer WM, Sacks FM, Ard J, et al. Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial. Ann Intern Med. Dec 18 2001;135(12):1019- 28. doi:10.7326/0003-4819-135-12-200112180-00005 141. Toledo E, Hu FB, Estruch R, et al. Effect of the Mediterranean diet on blood pressure in the PREDIMED trial: results from a randomized controlled trial. BMC Med. Sep 19 2013;11:207. doi:10.1186/1741-7015-11-207 142. Foti K, Moran AE, Matsushita K, et al. Evidence-Based, Streamlined Approach to Measure Blood Pressure in Primary Care Settings. Hypertension. Nov 26 2025;doi:10.1161/hypertensionaha.125.24527