Based on the available evidence, the benefits of this intervention outweigh the harms. Patient preferences vary regarding dietary modification; interested patients may prefer one dietary pattern over another. A Mediterranean-style dietary pattern may be beneficial to patients with HTN. It presents a viable alternative to the DASH diet for those who find lower fat diets unpalatable, have additional cardiovascular risk factors, or otherwise prefer the Mediterranean dietary pattern. Referral to a registered dietitian, when available, may help patients achieve the desired changes. D. Pharmacological Treatment a. For Hypertension Recommendation 23. We recommend offering a thiazide-type diuretic, calcium channel blocker, or either an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker as primary pharmacologic therapy for hypertension for reduction in composite cardiovascular outcomes. (Strong for | Reviewed, New-replaced) Discussion The effects of the various antihypertensive drug classes on reducing composite cardiovascular outcomes, and not just differences in blood pressure lowering effect, were the focus for the recommendation. The SR and meta-analysis of 50 RCTs by Thomopoulos et al. (2015) was the key body of evidence reviewed to recommend these four main drug classes as initial therapy for HTN.[135] 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 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. 