High blood pressure is a major risk factor for new-onset and recurrent cardiovascular disease, including coronary heart disease, stroke, and heart failure. Most of the early event-based trials of antihypertensive medication were primarily secondary prevention studies. For example, in the first randomized controlled trial (RCT) of antihypertensive medication versus placebo, 62% of the 87 trial participants had CVD at baseline. In subsequent antihypertensive drug treatment trials, with much larger sample sizes, stratified analysis suggested similar treatment benefits in those with or without CVD at baseline. Further, individual trials and meta-analyses in participants with CVD but without hypertension demonstrated that antihypertensive drug therapy was effective for the prevention of recurrent CVD. In recent trials of more intensive BP reduction, stratified analysis identified no difference in treatment benefit between those with or without CVD at baseline or between those with a higher or lower level of CVD risk at baseline. Clinical practice guidelines generally recommend a final SBP target of less than 130 mm Hg in adults with CVD.
Diuretics, ACEI, ARB, and CCB are the best-proven drug classes for antihypertensive therapy in adults without a compelling indication for choice of a particular BP-lowering medication. However, specific combinations are recommended for the management of hypertension in adults with an underlying co-morbidity such as stable ischemic heart disease (SIHD), stroke, heart failure, or kidney disease. Beta-blockers are first-line agents in adults with SIHD, diuretics and CCBs are preferred agents in adults with prior stroke, and long-acting thiazide-like agents are especially useful in adults with heart failure. BP/hypertension clinical practice guidelines provide detailed recommendations for choice of agents and BP targets in adults with hypertension and co-morbidities, including various forms of CVD.