When to start blood pressure (BP)-lowering therapy according to ASCVD risk estimate

For patients with established ASCVD, treatment with BP-lowering therapy (specifically with an angiotensin converting enzyme inhibitor [ACEI] or angiotensin II receptor blocker [ARB]) is recommended routinely. See also Secondary prevention of atherosclerotic cardiovascular events.

For patients at high ASCVD risk, treat with BP-lowering therapy in addition to lifestyle modification unless contraindicated or clinically inappropriate. Withholding treatment may be reasonable in some patients; for example, those who are hypotensive. See Blood pressure treatment targets for detailed advice.

For patients at intermediate ASCVD risk, consider starting BP-lowering drug therapy in addition to lifestyle modification, unless contraindicated or clinically inappropriate, and in discussion with the patient about their preferences.

Withholding treatment may be reasonable in some patients; for example, those who are hypotensive. See Blood pressure treatment targets for detailed advice.

For patients at low ASCVD risk, BP-lowering drug therapy is not routinely required. Discuss the likely benefits and harms of drug therapy with the patient and consider patient preference.