Expert Opinion Grade E a perceived need for further guidance to assist in implementation of recommendations 1 through 8. Recommendation 9 is based on strategies used in RCTs that demonstrated improved patient out- comesandtheexpertiseandclinicalexperienceofpanelmembers. Thisrecommendationdiffersfromtheotherrecommendationsbe- cause it was not developed in response to the 3 critical questions using a systematic review of the literature. The Figure is an algo- rithm summarizing the recommendations. However, this algo- rithmhasnotbeenvalidatedwithrespecttoachievingimprovedpa- tient outcomes. How should clinicians titrate and combine the drugs recom- mended in this report? There were no RCTs and thus the panel relied on expert opinion. Three strategies (Table 5) have been used in RCTs of high BP treatment but were not compared with each other. Based on the evidence reviewed for questions 1 through 3 and on the expert opinion of the panel members, it is not known if one of the strategies results in improved cardiovas- cular outcomes, cerebrovascular outcomes, kidney outcomes, or mortality compared with an alternative strategy. There is not likely to be evidence from well-designed RCTs that compare these 2014 Guideline for Management of High Blood Pressure Special Communication Clinical Review & Education jama.com JAMA Published online December 18, 2013 E9 Figure. 2014 Hypertension Guideline Management Algorithm Adult aged 18 years with hypertension Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or C. Start with 2 medication classes separately or as fixed-dose combination. Reinforce medication and lifestyle adherence. For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). For strategy C, titrate doses of initial medications to maximum. Reinforce medication and lifestyle adherence. 