There are NICE guidelines on acute coronary syndromes and chronic heart failure, and these guidelines make recommendations on drug treatment that overlap with treatment for hypertension. To avoid confusion over the treatment pathway, the committee highlighted that these condition-specific recommendations should be applied first (for example, when prescribing an ACE inhibitor or an ARB for secondary prevention of myocardial infarction). How the recommendations might affect practice The recommendation reflects current practice for most types of cardiovascular disease. The committee were aware that, after a stroke, the thiazide-like diuretic indapamide is sometimes used first, rather than a calcium channel blocker. However, it is unclear how common this is. As people with cardiovascular disease are commonly prescribed more than 1 antihypertensive drug, any impact on prescribing would be limited. Return to recommendation Step 1 treatment Why the committee made the recommendations The committee reviewed the evidence for starting treatment for primary hypertension with a single antihypertensive medicine compared with starting with 2 antihypertensive medicines at once (dual therapy). Additionally, the committee reviewed the evidence on whether specific subgroups of people with hypertension might benefit from starting on dual therapy, for example people with type 2 diabetes, older people, or those of particular family origins. Some limited evidence from a single study showed that initial dual therapy may reduce cardiovascular events in people with hypertension and type 2 diabetes, but the committee members were disappointed that more comprehensive data was not available. The committee discussed the benefits of optimising treatment for hypertension early and agreed that this can substantially improve quality of life. However, there was not enough evidence to determine confidently the benefits or harms of starting treatment with dual therapy. 